Preface

Chapter 9 **Probiotics, an Alternative Measure to Chemotherapy in Fish**

**Production 151**

**VI** Contents

Olumuyiwa Ayodeji Akanmu

The quality of our life is linked to our daily diet from food that is considered essential and indispensable to human life. Probiotic foods are a group of functional foods that have been used for centuries especially in fermented dairy products since Metchnikoff associated the intake of fermented milk with prolonged life. Probiotics confer many health benefits to hu‐ mans, animals, and plants when administered in proper amounts. Several recognized profits of probiotics have been proven including the prevention of gastrointestinal infections and antibiotic-associated diarrhea, the reduction of serum cholesterol and allergenic and atopic complaints, and the protection of the immune system. Furthermore, the proper usage of pro‐ biotics could suppress *Helicobacter pylori* infection and Crohn's disease, improve inflamma‐ tory bowel disease, and prevent cancer.

Many different microorganisms could exert these beneficial effects, and several studies showed the selection methods of strains with high probiotic effect and the development of technologies for the production of improved probiotics. In addition to that, they have been focused on the benefits of the combination of probiotic bacterial strains and prebiotics in functional foods.

We decided to write this book to discuss the different types of probiotic microorganisms and the uses of probiotics and their applications as presented by international leaders in their respective fields.

This book consists of several review chapters. Each chapter starts with a brief introduction, including its aims, and then goes on to provide detailed information about the current re‐ search relevant to the field. The authors give an overview of probiotics that they used in their research as important microorganisms that exert beneficial effects on humans and/or animals in a simple way that allows the readers to form a complete picture about these ben‐ eficial microorganisms and their suitability as therapeutic and prophylactic agents. Through these chapters, the authors explored the concept of probiotics and prebiotics and how the selection of probiotic microorganisms is done. They examined the beneficial effects of probi‐ otics and their different applications. Future aspects in the development of technologies for the production of improved probiotics are also reviewed here.

We believe that our book is an excellent one for scientists, especially those who are interest‐ ed in probiotics. We hope you enjoy reading it. Finally, we would like to thank all the contri‐ buting authors, without whose dedication and brilliant research, this project would not have been accomplished.

> **Dr. Shymaa Enany** Department of Microbiology and Immunology Faculty of Pharmacy Suez Canal University Ismailia, Egypt

**Chapter 1**

**Provisional chapter**

**Antimicrobial Effects of Probiotics and Novel Probiotic-**

Probiotics are live microorganisms, which confer health benefits on host when administered in adequate amounts. Probiotics exert their beneficial effects by maintenance flora healthy, enhancement of mucosal barrier integrity and modulation of immune responses. Antimicrobial substances including bacteriocins, hydrogen peroxide, organic acids, and short-chain fatty acids (SCFAs) produced by probiotics allow them to inhibit mucosal and epithelial adherence of pathogens and compete for limiting resources, thus suppress the growth of bacterial and fungal pathogens. Probiotics effect the colonization of fungal pathogen *Candida* to host surfaces, suppress *Candida* growth and biofilm development *in vitro*. Clinical results have shown that some probiotics can reduce oral, vaginal, and enteric colonization of *Candida*, alleviate clinical signs and symptoms, and potentially reduce the incidence of invasive fungal infection. Therefore, probiotics may

**Keywords:** probiotics, mechanism of action, antimicrobial activity, candidiasis, safety

Probiotics are "live microorganisms that, when administered in adequate amounts, confer a health benefit on the host," which was defined by the Food and Drug Organization of the United Nations (FAO) and World Health Organization (WHO) [1–3]. Probiotics should have some fundamental characteristics, such as human origin, nonpathogenic in nature, resistance to destruction by technical processing, acid and bile tolerances, adequate adherence and colonization on epithelial surfaces, antagonistic activity against pathogens, regulation of immune

be potential antifungals for prevention and treatment of candidiasis.

response, and influence human metabolic activities [4–7].

**Antimicrobial Effects of Probiotics and Novel Probiotic-**

DOI: 10.5772/intechopen.72804

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

**Based Approaches for Infectious Diseases**

**Based Approaches for Infectious Diseases**

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.72804

Ping Li and Qing Gu

**Abstract**

**1. Introduction**

Ping Li and Qing Gu

**Provisional chapter**

#### **Antimicrobial Effects of Probiotics and Novel Probiotic-Based Approaches for Infectious Diseases Based Approaches for Infectious Diseases**

**Antimicrobial Effects of Probiotics and Novel Probiotic-**

DOI: 10.5772/intechopen.72804

Ping Li and Qing Gu Ping Li and Qing Gu Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.72804

#### **Abstract**

Probiotics are live microorganisms, which confer health benefits on host when administered in adequate amounts. Probiotics exert their beneficial effects by maintenance flora healthy, enhancement of mucosal barrier integrity and modulation of immune responses. Antimicrobial substances including bacteriocins, hydrogen peroxide, organic acids, and short-chain fatty acids (SCFAs) produced by probiotics allow them to inhibit mucosal and epithelial adherence of pathogens and compete for limiting resources, thus suppress the growth of bacterial and fungal pathogens. Probiotics effect the colonization of fungal pathogen *Candida* to host surfaces, suppress *Candida* growth and biofilm development *in vitro*. Clinical results have shown that some probiotics can reduce oral, vaginal, and enteric colonization of *Candida*, alleviate clinical signs and symptoms, and potentially reduce the incidence of invasive fungal infection. Therefore, probiotics may be potential antifungals for prevention and treatment of candidiasis.

**Keywords:** probiotics, mechanism of action, antimicrobial activity, candidiasis, safety

#### **1. Introduction**

Probiotics are "live microorganisms that, when administered in adequate amounts, confer a health benefit on the host," which was defined by the Food and Drug Organization of the United Nations (FAO) and World Health Organization (WHO) [1–3]. Probiotics should have some fundamental characteristics, such as human origin, nonpathogenic in nature, resistance to destruction by technical processing, acid and bile tolerances, adequate adherence and colonization on epithelial surfaces, antagonistic activity against pathogens, regulation of immune response, and influence human metabolic activities [4–7].

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

Bacteria belonging to the genera *Lactobacillus* and *Bifidobacterium* are the most frequently used probiotics. Besides, *Enterococcus*, *Streptococcus*, *Saccharomyces*, and *Bacillus* are also commonly used probiotics (representative species are listed in **Table 1**). The administration of probiotics has been confirmed as an alternative biological approach to combat bacterial and fungal pathogens in the oral cavity, GI tract, and urogenital system [4, 5, 7–14]. It has been reported that probiotics could reduce *Candida*, which cause fungal infections in different organ systems of the human body and prevent bacterial infectious diseases [9, 10, 15]. Probiotics were capable of preventing cancers [16], modulating blood pressure [17, 18], and repressing cholesterol levels [19]. Recently, species of *Akkermansia muciniphila*, *Eubacterium hallii*, and *Faecalibacterium prausnitzii* are identified as new potential probiotics because of their great benefits to the microbial metabolic networks and human health, especially the effects on correcting the imbalance of gut microbiota composition [7, 20–22]. A combination of probiotics with traditional treatment has been thought to be a potential approach for treatment of certain diseases.

*plantarum, Lactobacillus casei*, and *Lactobacillus delbrueckii* subsp. bulgaricus) was proven more effective than single-strain probiotics for the treatment of ulcerative colitis [23]. The multispecies probiotic consortium, Ecologic AAD (*Bifidobacterium bifidum* W23, *Bifidobacterium lactis* W18, *Bifidobacterium longum* W51, *Enterococcus faecium* W54, *Lactobacillus acidophilus* W37 and W55, *Lactobacillus paracasei* W72, *Lactobacillus plantarum* W62, *Lactobacillus rhamnosus* W71, and *Lactobacillus salivarius* W24), combined with amoxicillin, could reduce diarrhea-like bowel movements, while the single strain could not [25]. Thus, the combination-specific probiotic

Antimicrobial Effects of Probiotics and Novel Probiotic-Based Approaches for Infectious Diseases

http://dx.doi.org/10.5772/intechopen.72804

3

Among the most frequently used probiotics, the genera *Lactobacillus, Bifidobacterium, Lactococcus*, and *Saccharomyces* have been included in the category of "generally regarded as safe" (GRAS) [4, 6]; however, other probiotic organisms such as *Enterococcus, Bacillus*, and *Streptococcus* are not generally regarded as safe. Since probiotics have been applied in food production, disease treatment, and others, it is important to undergo safety evaluation of

In this chapter, we briefly review the mechanisms of action of probiotics, the safety concern of probiotics, and their potentials for prevention and treatment of diseases. Here, we discuss the

Probiotics mechanism of action is with important differences among different species and

The ability of probiotics to establish in the gastrointestinal (GI) tract, maintain flora healthy, and reduce the growth of pathogens and colonization is enhanced by their ability to eliminate competitors. Probiotic strains release different antimicrobial molecules such as organic acids,

Lactic acid and acetic acid are the main metabolites formed by lactic acid bacteria (LAB). Both lactic acid and acetic acid could result in acidity environment and thus inhibit the growth of various microorganisms. Acetic acid has a broader spectrum of antimicrobial activity when compared to lactic acid. Moreover, it is known that a synergistic effect exists between the two acids: mixtures of acetic and lactic acids suppress the growth of the pathogenic enteric bacte-

dizing effect. Hydrogen peroxide showed a bactericidal effect on most pathogens when in

), and antimicrobial peptide bacteriocins into the intestinal environ-

, the antimicrobial activity of which is linked to the strong oxi-

application of probiotics in the fungal *Candida*-infected and invasion candidiasis.

**2.1. Maintenance flora healthy by reduction the growth and colonization** 

ment to limit the growth of bacterial and fungal pathogens [6, 39–43].

effects from diverse strains can lead to synergistic effects.

probiotics before human consumption.

**2. Probiotics mechanism of action**

О2

О2

strain, examples are listed in **Table 2**.

**of pathogens**

hydrogen peroxide (Н<sup>2</sup>

rium *Salmonella typhimurium* [44].

LAB can also produce Н<sup>2</sup>

It is noteworthy that health benefits of probiotic bacteria are strain specific, which cannot be generalized to other strains, not even the same species, although some properties may be common for different strains because of the similarities in the metabolism of ecological functionality [5, 6]. Thus, the selection of certain probiotics for therapeutic purposes should be targeted for specific pathogens. Probiotics effects are dose specific [5, 6]. It has been suggested that a daily intake of 10<sup>6</sup> –109 colony-forming units (CFUs) of probiotic microorganisms is the minimum effective dose for therapeutic purposes [5, 6, 8].

A number of probiotics are currently commercially available, and they have been categorized into single-strain or multi-strain/multispecies products [7, 23, 24]. Multi-strain/multispecies probiotics exhibited better effects than single-strain probiotics. The multispecies probiotic consortium VSL#3 (*Streptococcus thermophilus, Eubacterium faecium, Bifidobacterium breve, Bifidobacterium infantis, Bifidobacterium longum, Lactobacillus acidophilus, Lactobacillus* 


**Table 1.** Representative microbe commonly considered as probiotics.

*plantarum, Lactobacillus casei*, and *Lactobacillus delbrueckii* subsp. bulgaricus) was proven more effective than single-strain probiotics for the treatment of ulcerative colitis [23]. The multispecies probiotic consortium, Ecologic AAD (*Bifidobacterium bifidum* W23, *Bifidobacterium lactis* W18, *Bifidobacterium longum* W51, *Enterococcus faecium* W54, *Lactobacillus acidophilus* W37 and W55, *Lactobacillus paracasei* W72, *Lactobacillus plantarum* W62, *Lactobacillus rhamnosus* W71, and *Lactobacillus salivarius* W24), combined with amoxicillin, could reduce diarrhea-like bowel movements, while the single strain could not [25]. Thus, the combination-specific probiotic effects from diverse strains can lead to synergistic effects.

Among the most frequently used probiotics, the genera *Lactobacillus, Bifidobacterium, Lactococcus*, and *Saccharomyces* have been included in the category of "generally regarded as safe" (GRAS) [4, 6]; however, other probiotic organisms such as *Enterococcus, Bacillus*, and *Streptococcus* are not generally regarded as safe. Since probiotics have been applied in food production, disease treatment, and others, it is important to undergo safety evaluation of probiotics before human consumption.

In this chapter, we briefly review the mechanisms of action of probiotics, the safety concern of probiotics, and their potentials for prevention and treatment of diseases. Here, we discuss the application of probiotics in the fungal *Candida*-infected and invasion candidiasis.

#### **2. Probiotics mechanism of action**

Bacteria belonging to the genera *Lactobacillus* and *Bifidobacterium* are the most frequently used probiotics. Besides, *Enterococcus*, *Streptococcus*, *Saccharomyces*, and *Bacillus* are also commonly used probiotics (representative species are listed in **Table 1**). The administration of probiotics has been confirmed as an alternative biological approach to combat bacterial and fungal pathogens in the oral cavity, GI tract, and urogenital system [4, 5, 7–14]. It has been reported that probiotics could reduce *Candida*, which cause fungal infections in different organ systems of the human body and prevent bacterial infectious diseases [9, 10, 15]. Probiotics were capable of preventing cancers [16], modulating blood pressure [17, 18], and repressing cholesterol levels [19]. Recently, species of *Akkermansia muciniphila*, *Eubacterium hallii*, and *Faecalibacterium prausnitzii* are identified as new potential probiotics because of their great benefits to the microbial metabolic networks and human health, especially the effects on correcting the imbalance of gut microbiota composition [7, 20–22]. A combination of probiotics with traditional treat-

ment has been thought to be a potential approach for treatment of certain diseases.

that a daily intake of 10<sup>6</sup>

2 Probiotics - Current Knowledge and Future Prospects

**Genera Species**

–109

minimum effective dose for therapeutic purposes [5, 6, 8].

*helveticus*, and *Lactobacillus fermentium*

*Lactococcus Lactis* subsp. cremoris

*Enterococcus Enterococcus faecalis* and *Enterococcus faecium Saccharomyces Saccharomyces cerevisiae* and *Saccharomyces boulardii*

**Table 1.** Representative microbe commonly considered as probiotics.

*Bacillus Bacillus coagulans* and *Bacillus subtilis*

*Streptococcus Streptococcus thermophiles*

It is noteworthy that health benefits of probiotic bacteria are strain specific, which cannot be generalized to other strains, not even the same species, although some properties may be common for different strains because of the similarities in the metabolism of ecological functionality [5, 6]. Thus, the selection of certain probiotics for therapeutic purposes should be targeted for specific pathogens. Probiotics effects are dose specific [5, 6]. It has been suggested

A number of probiotics are currently commercially available, and they have been categorized into single-strain or multi-strain/multispecies products [7, 23, 24]. Multi-strain/multispecies probiotics exhibited better effects than single-strain probiotics. The multispecies probiotic consortium VSL#3 (*Streptococcus thermophilus, Eubacterium faecium, Bifidobacterium breve, Bifidobacterium infantis, Bifidobacterium longum, Lactobacillus acidophilus, Lactobacillus* 

*Lactobacillus Lactobacillus rhamnosus*, *Lactobacillus casei*, *Lactobacillus plantarum*, *Lactobacillus acidophilus*,

*Lactococcus Lactococcus lactis*, *Lactococcus lactis* subsp. lactis, *Lactococcus lactis* subsp. diacetylactis, and

Others *Akkermansia muciniphila*, *Eubacterium hallii*, and *Faecalibacterium prausnitzii*

*Bifidobacterium Bifidobacterium longum*, *Bifidobacterium bifidum*, *Bifidobacterium bifidus*, and *Bifidobacterium lactis*

*Lactobacillus reuteri*, *Lactobacillus paracasei*, *Lactobacillus sporogenes*, *Lactobacillus lactis, Lactobacillus* 

colony-forming units (CFUs) of probiotic microorganisms is the

Probiotics mechanism of action is with important differences among different species and strain, examples are listed in **Table 2**.

#### **2.1. Maintenance flora healthy by reduction the growth and colonization of pathogens**

The ability of probiotics to establish in the gastrointestinal (GI) tract, maintain flora healthy, and reduce the growth of pathogens and colonization is enhanced by their ability to eliminate competitors. Probiotic strains release different antimicrobial molecules such as organic acids, hydrogen peroxide (Н<sup>2</sup> О2 ), and antimicrobial peptide bacteriocins into the intestinal environment to limit the growth of bacterial and fungal pathogens [6, 39–43].

Lactic acid and acetic acid are the main metabolites formed by lactic acid bacteria (LAB). Both lactic acid and acetic acid could result in acidity environment and thus inhibit the growth of various microorganisms. Acetic acid has a broader spectrum of antimicrobial activity when compared to lactic acid. Moreover, it is known that a synergistic effect exists between the two acids: mixtures of acetic and lactic acids suppress the growth of the pathogenic enteric bacterium *Salmonella typhimurium* [44].

LAB can also produce Н<sup>2</sup> О2 , the antimicrobial activity of which is linked to the strong oxidizing effect. Hydrogen peroxide showed a bactericidal effect on most pathogens when in


Bacteriocins are ribosomally synthesized antimicrobial peptides, which have broad spectrum of inhibitory effect against Gram-positive and Gram-negative bacteria, viruses, and fungi [47–50]. *L. plantarum* 2.9, a bacteriocinogenic strain, inhibited a set of foodborne pathogens including *B. cereus*, *E. coli* O157:H7, and *S. enterica* [51]. Bacteriocin-producing strains identified in our lab, e.g., *L. plantarum* ZJ316, *L. plantarum* LZ95, *L. plantarum* ZJ008, and *L. plantarum* ZJ005, showed antimicrobial activity against various pathogens *in vitro* such as *S. aureus*, *E. coli*,

Antimicrobial Effects of Probiotics and Novel Probiotic-Based Approaches for Infectious Diseases

http://dx.doi.org/10.5772/intechopen.72804

5

Probiotics have been shown to improve barrier function and the mechanisms of barrier function including alteration of tight junction protein expression and/or localization, induction of mucus secretion, increased production of cytoprotective molecules such as heat-shock proteins, inhibition of apoptosis of epithelial cells, and promoting cell survival [29, 55, 56]. They compete with pathogens and prevent their invasion through the epithelium by the ability of adherence to the intestinal epithelium and mucus. *L. plantarum* has been shown to enhance mucosal barrier by adhering to the mucosal membrane and reducing Gram-negative bacteria [29]. Probiotics also compete for limiting resources, thus suppressing the growth of bacterial and fungal pathogens. The probiotic *E. coli* Nissle 1917 is able to effectively take up multiple limited environmental irons and simultaneously competitively inhibit the growth of other

Furthermore, butyrate, a short-chain fatty acid (SCFA), could reduce bacterial translocation, improve the organization of tight junctions, modulate intestinal motility in addition to being an energy source for colonocytes, and maintain the integrity of the intestinal epithelium [29–31, 58–60]. *E. hallii* is an important anaerobic butyrate producer resident in our gut, which influences the intestinal metabolic balance and enhances the host-gut microbiota homeostasis [61]. Thus, the administration of probiotics with butyrate-producing bacteria, in particular,

Probiotics are reported to enhance phagocytic activity of granulocytes and cytokine excretion in lymphocytes, increase immunoglobulin-secreting cells, and attenuate inflammasome activation. They are able to affect cells involved in immune responses, including epithelial cells, dendritic cells (DCs), T cells, regulatory T (Treg) cells, monocytes/macrophages, immu-

Probiotic bacteria have an effect on intestinal DCs, which have the ability to recognize and respond to different bacteria by linking the innate immune system to the adaptive immune response and to develop T- and B-cell responses. Badia et al. found that the immunomodulatory role of *S. boulardii* in the DCs prior to infection was related to the upregulation of tumor necrosis factor alpha (TNFα) and C─C chemokine receptor type 7 mRNAs, which might make the DCs more effective in antagonizing bacteria [64, 65]. Smith et al. reported that *S. boulardii* stimulated the production of cytokines TNFα, IL-1, IL-12, IL-6, and IL-10 in DCs and also

*S. enterica*, *L. monocytogenes*, and *C. albicans* [42, 52–54].

**2.2. Enhancement of mucosal barrier integrity**

intestinal microbes and pathogens [57].

**2.3. Immune modulation**

could be an effective way to achieve health benefits.

noglobulin A (IgA)-producing B cells, and natural killer cells [62, 63].

**Table 2.** Mechanism of action of probiotics.

combination with lactoperoxidase-thiocyanate milk system [45]. *L. johnsonii* NCC933 and *L. gasseri* KS120.1 killed enteric uropathogenic and vaginosis-associated pathogens due to the production of lactic acid and hydrogen peroxide [46].

Bacteriocins are ribosomally synthesized antimicrobial peptides, which have broad spectrum of inhibitory effect against Gram-positive and Gram-negative bacteria, viruses, and fungi [47–50]. *L. plantarum* 2.9, a bacteriocinogenic strain, inhibited a set of foodborne pathogens including *B. cereus*, *E. coli* O157:H7, and *S. enterica* [51]. Bacteriocin-producing strains identified in our lab, e.g., *L. plantarum* ZJ316, *L. plantarum* LZ95, *L. plantarum* ZJ008, and *L. plantarum* ZJ005, showed antimicrobial activity against various pathogens *in vitro* such as *S. aureus*, *E. coli*, *S. enterica*, *L. monocytogenes*, and *C. albicans* [42, 52–54].

#### **2.2. Enhancement of mucosal barrier integrity**

Probiotics have been shown to improve barrier function and the mechanisms of barrier function including alteration of tight junction protein expression and/or localization, induction of mucus secretion, increased production of cytoprotective molecules such as heat-shock proteins, inhibition of apoptosis of epithelial cells, and promoting cell survival [29, 55, 56]. They compete with pathogens and prevent their invasion through the epithelium by the ability of adherence to the intestinal epithelium and mucus. *L. plantarum* has been shown to enhance mucosal barrier by adhering to the mucosal membrane and reducing Gram-negative bacteria [29]. Probiotics also compete for limiting resources, thus suppressing the growth of bacterial and fungal pathogens. The probiotic *E. coli* Nissle 1917 is able to effectively take up multiple limited environmental irons and simultaneously competitively inhibit the growth of other intestinal microbes and pathogens [57].

Furthermore, butyrate, a short-chain fatty acid (SCFA), could reduce bacterial translocation, improve the organization of tight junctions, modulate intestinal motility in addition to being an energy source for colonocytes, and maintain the integrity of the intestinal epithelium [29–31, 58–60]. *E. hallii* is an important anaerobic butyrate producer resident in our gut, which influences the intestinal metabolic balance and enhances the host-gut microbiota homeostasis [61]. Thus, the administration of probiotics with butyrate-producing bacteria, in particular, could be an effective way to achieve health benefits.

#### **2.3. Immune modulation**

combination with lactoperoxidase-thiocyanate milk system [45]. *L. johnsonii* NCC933 and *L. gasseri* KS120.1 killed enteric uropathogenic and vaginosis-associated pathogens due to the

**Probiotics Study outcomes References**

probiotic group

controls

*B. lactis* Bb12 for 7–21 days (RCT) Probiotic group had great higher counts of

respectively

VSL#3 (RCT) Decreased incidence of bacterial translocation

protein

*L. plantarum* 299v (RCT) Late attenuating effect (after 15 days), serum IL-6 levels reduced

50%; P = 0.03)

Microencapsulated *Bifidobacteria* Bacterial translocation to mesenteric

*L. rhamnosus* GG showed the strongest inhibitory activity in fructose and glucose medium against *C. albicans*, followed by *L. casei* Shirota, *L. reuteri* SD2112 and *L. brevis* CD2

Increased survival of mice infected by multidrug resistant *P. aeruginosa* and *E. coli*

Levels of beneficial organic acids significantly increased in the gut, and the incidences of infectious (pneumonia and bacteremia) complications were significantly lower in the

Acetic acid concentration significantly increased (100 times), pH value decreased, Gramnegative rod (1/10) in the gut decreased, and *P. aeruginosa* decreased in the probiotic group

Synbiotic group had lower pathogenic bacteria (43% versus 75%) and multiple organisms (39% versus 75%) in nasogastric aspirates than

*Bifidobacterium* (P = 0.001) and lower counts of *Enterobacteriaceae* (P = 0.015) and *Clostridium* spp. (P = 0.014) than in placebo group

Colonization of *Candida* in gut was reduced in

Bacterial translocation in mesenteric lymph nodes and liver was reduced to 0 and 12%,

lymph nodes was reduced by encapsulated

in VSL#3 group than in water group (8% versus

Reduced acute physiology and chronic health evaluation II score; reduced sequential organ failure assessment, IL-6, procalcitonin, and

probiotic group (P = 0.01)

*Bifidobacteria* (P < 0.05)

[26]

[27]

[32]

[33]

[34]

[35]

[28]

[29]

[30]

[31]

[36]

[37]

production of lactic acid and hydrogen peroxide [46].

**Mechanism of action**

Maintenance flora healthy by reduction the growth and colonization of pathogens

CD2

4 Probiotics - Current Knowledge and Future Prospects

*L. rhamnosus* GG, *L. casei* Shirota, *L. reuteri* SD2112 and *L. brevis*

*L. plantarum,* commercial preparation LactoLevure®

Synbiotic (*Lactobacillus, Bifidobacterium*, and galactooligosaccharides) for

Multi-strain synbiotic for 7 days

*L. casei* subsp. *rhamnosus* for

*L. plantarum* 299v for 8 days

VSL#3 (*Lactobacillus*, *Bifidobacterium*, and

*S. thermophilus*) for 7 days (RCT)

8 weeks (RCT)

6 weeks (RCT)

(RCT)

**Table 2.** Mechanism of action of probiotics.

Enhancement of mucosal barrier integrity

Immune modulation (RCT)

*B. breve, L. casei* (randomized controlled trial, RCT)

> Probiotics are reported to enhance phagocytic activity of granulocytes and cytokine excretion in lymphocytes, increase immunoglobulin-secreting cells, and attenuate inflammasome activation. They are able to affect cells involved in immune responses, including epithelial cells, dendritic cells (DCs), T cells, regulatory T (Treg) cells, monocytes/macrophages, immunoglobulin A (IgA)-producing B cells, and natural killer cells [62, 63].

> Probiotic bacteria have an effect on intestinal DCs, which have the ability to recognize and respond to different bacteria by linking the innate immune system to the adaptive immune response and to develop T- and B-cell responses. Badia et al. found that the immunomodulatory role of *S. boulardii* in the DCs prior to infection was related to the upregulation of tumor necrosis factor alpha (TNFα) and C─C chemokine receptor type 7 mRNAs, which might make the DCs more effective in antagonizing bacteria [64, 65]. Smith et al. reported that *S. boulardii* stimulated the production of cytokines TNFα, IL-1, IL-12, IL-6, and IL-10 in DCs and also

induced high levels of costimulatory molecules CD80 and CD86, thus modulated the immune system and led to an efficient clearing of enteropathogenic bacteria from the blood stream coupled with a faster cytokine response [65, 66].

**Probiotics Target pathogen Study outcome References**

*S. boulardii C. albicans* SC5314 *S. boulardii* inhibited the affecting hyphae

*albicans* by H<sup>2</sup>

Antimicrobial Effects of Probiotics and Novel Probiotic-Based Approaches for Infectious Diseases

mechanism

*C. albicans* ATCC 14053 Strong inhibition of *C. albicans* by

*C. albicans* 10341 Significant inhibitory effect on biofilm

*C. albicans* SC5314 Visible inhibition zones of fungal *C.* 

the H<sup>2</sup> O2

factors

spp. (RCT)

(RCT)

*Candida* spp. 276 elderly people: probiotic intervention

*Candida* spp. 55 women: probiotics significant reduced

*Candida* spp. 150 children (aged 3 month to 12 year) on

urine (RCT)

*Candida* spp. 65 patients with *Candida*-associated

(RCT)

*Candida* spp. (RCT)

*L. acidophilus* ATCC 4356 *C. albicans* ATCC 18804 Reduce growth of *C. albicans* cells by 45.1% [78] *L. casei* subsp. *rhamnosus Candida* spp. 80 preterm neonates with a very low birth

*Lactobacillus* spp.

All probiotics inhibited the growth of *C.* 

formation, *Candida* adhesion, and biofilm formation by capric acid production

High activity toward *Candida* strains except

production and alternative

http://dx.doi.org/10.5772/intechopen.72804

[81]

7

[87]

[79]

[86]

[80]

[77]

[28]

[76]

[82]

[83]

[84]

O2

*C. glabrata* and *C. tropicalis*

supernatant of selenium-enriched

formation and reduce viability of *Candida*

*albicans* by probiotic treatment; low pH environment caused by lactic acid and

weight: probiotic reduced incidence and intensity of enteric colonization by *Candida*

reduced the risk of high yeast counts by 75% and the prevalence of hyposalivation

vaginal discharge, itching, and/or burning vaginal feeling, dyspareunia, and/or dysuria, and reduced the presence of

broad-spectrum antibiotics for at least 48 h: probiotic therapy avoided a significant increase in the number of patients colonized by *Candida* spp., significantly reduced the presence of *Candida* in the

stomatitis: detection rate of *Candida* spp. was reduced in the probiotic group; significant relief of clinical signs and symptoms after probiotic administration

production may be anti-*Candida*

*C. albicans* and *C. pseudotropicalis*

*C. parapsilosis*, and *C.* 

*tropicalis*

14 strains:

with SeNPs

*reuteri* RC-14

*L. fermentum*, *L. rhamnosus*, *L. plantarum*, and *L. acidophilus*

*L. plantarum* ATCC 8014 and *L. johnsonii* enriched or not

*L. acidophilus*, *L. rhamnosus*, *L. salivarius*, *B. bifidum*, *S. thermophiles*, and *B. infantis*

*L. rhamnosus* GR-1 *and L.* 

*L. rhamnosus GG*, *L. rhamnosus LC705*, *P. freudenreichii* subsp. *shermanii* JS

*L. rhamnosus* GR-1 *and L.* 

*L. acidophilus*, *L. rhamnosus*, *B. longum*, *B. bifidum*, *S. boulardii*, *and S. thermophilus*

*L. bulgaricus*, *B. longum*, *and* 

*S. thermophilus*

*reuteri* RC-14

*L. paracasei* IMC 502 *C. glabrata*, *C. krusei*,

Probiotics also influence intestinal epithelial cells through interaction with Toll-like receptors (TLRs) and downregulate the expression of NF-κB and proinflammatory cytokines [67, 68]. This effect is supported by the following studies: the supernatant of probiotic *Faecalibacterium prausnitzii* inhibited the NF-κB pathway *in vitro* and *in vivo* and showed protective effects in different models such as dinitrobenzene sulfate (DNBS)-induced colitis model and dextran sodium sulfate (DSS)-induced colitis [69]; the probiotic strain *L. rhamnosus* GG prevented cytokine-induced apoptosis in intestinal epithelial cells [70]; and *L. rhamnosus* GR-1 reduced the adhesion of *E. coli* by promoting TLR2 and NOD1 synergism and attenuating ASCindependent NLRP3 inflammasome activation [71].

## **3. Probiotic as antifungals for prevention and treatment of candidiasis**

*Candida* is an opportunistic pathogen, causing mucosal infections including infections in the oral cavity, oropharynx, esophagus, and vagina, and potentially life-threatening systemic candidiasis. *Candida albicans* is the most common fungal pathogen in humans responsible for causing superficial as well as deep invasive candidiasis, which are essentially caused by *Candida* biofilms attached to body surfaces. Other *Candida* species such as *Candida tropicalis*, *Candida guilliermondii*, *Candida krusei*, and *Candida glabrata* are less frequently isolated in healthy and diseased humans [72–74]. Probiotics are known to reduce *Candida* infection in different organs and are generally considered to be beneficial for overall health. They appear to assist the host combat the pathogen by suppressing filamentation formation and reducing biofilm development, the mechanism of which may be related to expression of genes associated with biofilm formation and filamentation in *Candida* species. *In vitro* and *in vivo* studies have demonstrated the role of probiotics in the prevention of *Candida* colonization and invasive candidiasis [38, 75–86].

#### **3.1.** *In vitro* **evidences: probiotics in prevention/treatment of** *Candida* **infections**

Several *in vitro* studies have addressed the antifungal effects of probiotics against *Candida* isolated from the human oral cavity, GI tract, and genitourinary tract [77–81, 86, 87]. The probiotics that have been investigated against *Candida* species include *Lactobacillus* (e.g., *L. rhamnosus*, *L. plantarum*, *L. fermentum*, *L. acidophilus*, *L. paracasei*, *L. johnsonii*, and *L. salivarius*), *Bifidobacterium* (e.g., *B. bifidum* and *B. infantis*), *Saccharomyces* (e.g., *S. boulardii*), and *Streptococcus* (e.g., *S. thermophilus*). **Table 3** shows candidacidal activity of probiotic strains in different studies. *C. albicans* appears to be more susceptible to the antifungal effect of *Lactobacillus* than *C. pseudotropicalis* [81], and the probiotics exhibited growth inhibitory activities against *C. glabrata, C. krusei*, and *C. parapsilosis* [79, 87].

Antimicrobial Effects of Probiotics and Novel Probiotic-Based Approaches for Infectious Diseases http://dx.doi.org/10.5772/intechopen.72804 7

induced high levels of costimulatory molecules CD80 and CD86, thus modulated the immune system and led to an efficient clearing of enteropathogenic bacteria from the blood stream

Probiotics also influence intestinal epithelial cells through interaction with Toll-like receptors (TLRs) and downregulate the expression of NF-κB and proinflammatory cytokines [67, 68]. This effect is supported by the following studies: the supernatant of probiotic *Faecalibacterium prausnitzii* inhibited the NF-κB pathway *in vitro* and *in vivo* and showed protective effects in different models such as dinitrobenzene sulfate (DNBS)-induced colitis model and dextran sodium sulfate (DSS)-induced colitis [69]; the probiotic strain *L. rhamnosus* GG prevented cytokine-induced apoptosis in intestinal epithelial cells [70]; and *L. rhamnosus* GR-1 reduced the adhesion of *E. coli* by promoting TLR2 and NOD1 synergism and attenuating ASC-

*Candida* is an opportunistic pathogen, causing mucosal infections including infections in the oral cavity, oropharynx, esophagus, and vagina, and potentially life-threatening systemic candidiasis. *Candida albicans* is the most common fungal pathogen in humans responsible for causing superficial as well as deep invasive candidiasis, which are essentially caused by *Candida* biofilms attached to body surfaces. Other *Candida* species such as *Candida tropicalis*, *Candida guilliermondii*, *Candida krusei*, and *Candida glabrata* are less frequently isolated in healthy and diseased humans [72–74]. Probiotics are known to reduce *Candida* infection in different organs and are generally considered to be beneficial for overall health. They appear to assist the host combat the pathogen by suppressing filamentation formation and reducing biofilm development, the mechanism of which may be related to expression of genes associated with biofilm formation and filamentation in *Candida* species. *In vitro* and *in vivo* studies have demonstrated the role of probiotics in the prevention of *Candida* colonization and inva-

**3.1.** *In vitro* **evidences: probiotics in prevention/treatment of** *Candida* **infections**

ties against *C. glabrata, C. krusei*, and *C. parapsilosis* [79, 87].

Several *in vitro* studies have addressed the antifungal effects of probiotics against *Candida* isolated from the human oral cavity, GI tract, and genitourinary tract [77–81, 86, 87]. The probiotics that have been investigated against *Candida* species include *Lactobacillus* (e.g., *L. rhamnosus*, *L. plantarum*, *L. fermentum*, *L. acidophilus*, *L. paracasei*, *L. johnsonii*, and *L. salivarius*), *Bifidobacterium* (e.g., *B. bifidum* and *B. infantis*), *Saccharomyces* (e.g., *S. boulardii*), and *Streptococcus* (e.g., *S. thermophilus*). **Table 3** shows candidacidal activity of probiotic strains in different studies. *C. albicans* appears to be more susceptible to the antifungal effect of *Lactobacillus* than *C. pseudotropicalis* [81], and the probiotics exhibited growth inhibitory activi-

coupled with a faster cytokine response [65, 66].

6 Probiotics - Current Knowledge and Future Prospects

independent NLRP3 inflammasome activation [71].

**candidiasis**

sive candidiasis [38, 75–86].

**3. Probiotic as antifungals for prevention and treatment of** 



GR-1 and *L. reuteri* RC-14 significantly reduced the presence of *Candida* and therefore reduced the vaginal discharge, itching, and/or burning vaginal feeling, dyspareunia, and/or dysuria [82]. For the GI tract, *Candida* species are common inhabitants of GI tract. Dysbiosis of GI tract may lead to candidal overgrowth and possible invasive infections, especially in infants. Hence, immunocompromised children, especially preterm neonates with low birth weight, have been the target population of a large number of studies to evaluate the prevention or/and treatment potentials of probiotics to *Candida* infections [28, 75, 83]. Manzoni et al., in an RCT involving 80 very low birth weight (VLBW) neonates, demonstrated that orally administered *L. casei* subsp. rhamnosus significantly reduced incidence and intensity of enteric colonization by *Candida* [28]. Another RCT, by Roy et al., found *L. acidophilus*, *B. lactis*, *B. longum*, and *B. bifidum* reduced enteral fungal colonization and invasive fungal sepsis in 112 preterm neonates

Antimicrobial Effects of Probiotics and Novel Probiotic-Based Approaches for Infectious Diseases

http://dx.doi.org/10.5772/intechopen.72804

9

Together, both the laboratory studies and clinical studies showed that probiotics could prevent *Candida* colonization by inhibiting adhesion, filamentation, and biofilm formation, and therefore supplementation of probiotics could be a potential approach for reducing *Candida*

Although most commercially available probiotic strains are generally regarded as safe and none of the clinical studies mentioned above were reported to have adverse effects directly related to probiotics, there are some concerns regarding the safety of probiotics, including potential of bacteremia and/or endocarditis occurrence, toxicity to the gastrointestinal tract,

Lactic acid bacteria, including *Bifidobacterium*, have been reported to cause bacteremia as well as endocarditis [88–92]. Cannon et al. described that *L. rhamnosus* caused liver abscess, lactobacillemia, and infective endocarditis in a few case studies, and also the occurrence of *Lactobacillus* sepsis was directly linked with the ingestion of probiotic supplements, especially among immunocompromised patients and those with endocarditis [89]. Kunz et al. found two premature infants with short gut syndrome developed Lactobacillus bacteremia while taking *Lactobacillus* GG supplements. However, the risk of infection due to Lactobacilli is extremely rare. Statistic data from surveillance in Finland suggest that there was no increase in *Lactobacillus* bacteremia

The role of probiotics on gastrointestinal physiology suggests a theoretical possibility that the production of metabolites might be undesirable and also might lead to malabsorption due to deconjugation of bile salts. These might increase the risk of colon cancer; however, there is no

during 1990–2000, and Lactobacilli were isolated in 0.02% of all blood cultures [93].

epidemiologic or clinical evidence to support this hypothesis [94, 95].

(gestational age < 37 wk and birth weight < 2500 g) [75].

colonization and invasive candidiasis.

and transfer of antibiotic resistance [4].

**4.2. Toxicity to the gastrointestinal tract**

**4.1. Potential of bacteremia and/or endocarditis occurrence**

**4. Safety of probiotics**

**Table 3.** Probiotics in prevention/treatment of *Candida* infections.

However, the mechanisms involved in antifungal activity of probiotics against *Candida* remain unclarified. Strus et al. found that *Lactobacillus* strains could inhibit the growth of *C. albicans* to a certain degree and their anticandidal activity related to H<sup>2</sup> O2 production [81]. Murzyn et al. reported that *S. boulardii* was able to secrete active compounds, mainly capric acid, reduced the expression of *hwp1*, *ino1*, and *csh1* genes that encode virulence factors in *C. albicans* SC5314 cells, and inhibited filamentation of *C. albicans* and its mycelial development [87]. Therefore, it is likely that the antimicrobial molecules, organic acids, and Н<sup>2</sup> О2 produced by probiotic are major factors to limit growth of fungal pathogen *Candida.* This idea was supported by the research of Köhler et al. They demonstrated that low pH environment caused by lactic acid and the H<sup>2</sup> O2 production of *L. rhamnosus* GR-1 and *L. reuteri* RC-14 strains played important role in their inhibition activity to *C. albicans* SC5314. Moreover, *L. rhamnosus* GR-1 and *L. reuteri* RC-14 inhibited genes associated with *C. albicans* biofilm formation [87]. This result, together with the findings in Murzyn et al. study, shed light on a novel approach for uncovering the molecular mechanisms of the probiotic effect by using gene expression and related technology.

#### **3.2.** *In vivo* **evidences: probiotics in prevention/treatment of** *Candida* **infections**

*In vivo* studies, especially RCTs, have also been performed to substantiate the antifungal activity of probiotics in humans. These studies mostly focus on the sites of oral cavity, GI tract, and urogenital tract, which are susceptible to *Candida* infections (**Table 3**).

The elderly are a group particularly susceptible to oral candidiasis, because of frequent usage of dentures, hyposalivation, and their weakened immune status. Researches by Hatakka et al. and Kraft-Bodi et al. have shown that the daily consumption of food with *L. reuteri* DSM17938, *L. reuteri* ATCC PTA 5289, and *L. rhamnosus* GG ATCC 53103 significantly reduced the high yeast counts in saliva and biofilms in the elderly [76, 85]. The removal of biofilms by the use of probiotics that reduce the oral burden of *Candida* could play a major role in preventing oral candidiasis in denture wearers.

For the urogenital tract, chronic vulvovaginal candidiasis (VVC) is the most common candidiasis disease and impacts the life quality of thousands of women around the world. Researches on the effect of probiotics in the treatment and prophylaxis of VVC have been performed [82]. Martinez et al., in an RCT involving 55 women, demonstrated that the administration of *L. rhamnosus*

GR-1 and *L. reuteri* RC-14 significantly reduced the presence of *Candida* and therefore reduced the vaginal discharge, itching, and/or burning vaginal feeling, dyspareunia, and/or dysuria [82].

For the GI tract, *Candida* species are common inhabitants of GI tract. Dysbiosis of GI tract may lead to candidal overgrowth and possible invasive infections, especially in infants. Hence, immunocompromised children, especially preterm neonates with low birth weight, have been the target population of a large number of studies to evaluate the prevention or/and treatment potentials of probiotics to *Candida* infections [28, 75, 83]. Manzoni et al., in an RCT involving 80 very low birth weight (VLBW) neonates, demonstrated that orally administered *L. casei* subsp. rhamnosus significantly reduced incidence and intensity of enteric colonization by *Candida* [28]. Another RCT, by Roy et al., found *L. acidophilus*, *B. lactis*, *B. longum*, and *B. bifidum* reduced enteral fungal colonization and invasive fungal sepsis in 112 preterm neonates (gestational age < 37 wk and birth weight < 2500 g) [75].

Together, both the laboratory studies and clinical studies showed that probiotics could prevent *Candida* colonization by inhibiting adhesion, filamentation, and biofilm formation, and therefore supplementation of probiotics could be a potential approach for reducing *Candida* colonization and invasive candidiasis.

### **4. Safety of probiotics**

However, the mechanisms involved in antifungal activity of probiotics against *Candida* remain unclarified. Strus et al. found that *Lactobacillus* strains could inhibit the growth of *C. albicans*

**Probiotics Target pathogen Study outcome References**

*Candida* spp. 112 preterm neonates (gestational age < 37

neonates (RCT)

saliva and plaque (RCT)

*Candida* spp. 215 elderly people (aged 60–102 y):

al. reported that *S. boulardii* was able to secrete active compounds, mainly capric acid, reduced the expression of *hwp1*, *ino1*, and *csh1* genes that encode virulence factors in *C. albicans* SC5314 cells, and inhibited filamentation of *C. albicans* and its mycelial development [87]. Therefore,

are major factors to limit growth of fungal pathogen *Candida.* This idea was supported by the research of Köhler et al. They demonstrated that low pH environment caused by lactic

tant role in their inhibition activity to *C. albicans* SC5314. Moreover, *L. rhamnosus* GR-1 and *L. reuteri* RC-14 inhibited genes associated with *C. albicans* biofilm formation [87]. This result, together with the findings in Murzyn et al. study, shed light on a novel approach for uncovering the molecular mechanisms of the probiotic effect by using gene expression and related

*In vivo* studies, especially RCTs, have also been performed to substantiate the antifungal activity of probiotics in humans. These studies mostly focus on the sites of oral cavity, GI tract, and

The elderly are a group particularly susceptible to oral candidiasis, because of frequent usage of dentures, hyposalivation, and their weakened immune status. Researches by Hatakka et al. and Kraft-Bodi et al. have shown that the daily consumption of food with *L. reuteri* DSM17938, *L. reuteri* ATCC PTA 5289, and *L. rhamnosus* GG ATCC 53103 significantly reduced the high yeast counts in saliva and biofilms in the elderly [76, 85]. The removal of biofilms by the use of probiotics that reduce the oral burden of *Candida* could play a major role in preventing oral

For the urogenital tract, chronic vulvovaginal candidiasis (VVC) is the most common candidiasis disease and impacts the life quality of thousands of women around the world. Researches on the effect of probiotics in the treatment and prophylaxis of VVC have been performed [82]. Martinez et al., in an RCT involving 55 women, demonstrated that the administration of *L. rhamnosus*

**3.2.** *In vivo* **evidences: probiotics in prevention/treatment of** *Candida* **infections**

urogenital tract, which are susceptible to *Candida* infections (**Table 3**).

production of *L. rhamnosus* GR-1 and *L. reuteri* RC-14 strains played impor-

O2

wk and birth weight < 2500 g): probiotics may reduce enteral fungal colonization and invasive fungal sepsis in low-birth-weight

significant reduction of *Candida* cells in

О2

production [81]. Murzyn et

[75]

[85]

produced by probiotic

to a certain degree and their anticandidal activity related to H<sup>2</sup>

**Table 3.** Probiotics in prevention/treatment of *Candida* infections.

it is likely that the antimicrobial molecules, organic acids, and Н<sup>2</sup>

acid and the H<sup>2</sup>

*L. acidophilus*, *B. lactis*, *B. longum*, *and B. bifidum*

8 Probiotics - Current Knowledge and Future Prospects

*L. reuteri* DSM 17938 and *L. reuteri* ATCC PTA 5289

technology.

O2

candidiasis in denture wearers.

Although most commercially available probiotic strains are generally regarded as safe and none of the clinical studies mentioned above were reported to have adverse effects directly related to probiotics, there are some concerns regarding the safety of probiotics, including potential of bacteremia and/or endocarditis occurrence, toxicity to the gastrointestinal tract, and transfer of antibiotic resistance [4].

#### **4.1. Potential of bacteremia and/or endocarditis occurrence**

Lactic acid bacteria, including *Bifidobacterium*, have been reported to cause bacteremia as well as endocarditis [88–92]. Cannon et al. described that *L. rhamnosus* caused liver abscess, lactobacillemia, and infective endocarditis in a few case studies, and also the occurrence of *Lactobacillus* sepsis was directly linked with the ingestion of probiotic supplements, especially among immunocompromised patients and those with endocarditis [89]. Kunz et al. found two premature infants with short gut syndrome developed Lactobacillus bacteremia while taking *Lactobacillus* GG supplements. However, the risk of infection due to Lactobacilli is extremely rare. Statistic data from surveillance in Finland suggest that there was no increase in *Lactobacillus* bacteremia during 1990–2000, and Lactobacilli were isolated in 0.02% of all blood cultures [93].

#### **4.2. Toxicity to the gastrointestinal tract**

The role of probiotics on gastrointestinal physiology suggests a theoretical possibility that the production of metabolites might be undesirable and also might lead to malabsorption due to deconjugation of bile salts. These might increase the risk of colon cancer; however, there is no epidemiologic or clinical evidence to support this hypothesis [94, 95].

#### **4.3. Transfer of antibiotic resistance**

Another major safety concern of theoretical importance is genetic transfer of antibiotic resistance from probiotic strains to pathogenic cells in the gastrointestinal tract [96, 97]. Plasmids with antibiotic-resistance genes, including genes encoding resistance to tetracycline, erythromycin, chloramphenicol, and macrolide-lincosamide-streptogramin, have been found in *L. plantarum*, *L. fermentum*, *L. acidophilus*, and *L. reuteri* strains. *L. plantarum* 5057 exhibited tetracycline resistance, and *L. lactis* was with streptomycin, tetracycline, and chloramphenicol resistances [98–100]. Although the transfer of native *Lactobacillus* plasmids is quite rare, there are some cases, e.g., the antibiotic-resistance plasmids from *Lactococcus* species could transfer to *Leuconostoc* species and *Pediococcus* species.

**References**

**39**:237-238

[1] Hill C, Guarner F, Reid G, Gibson GR, Merenstein DJ, Pot B, 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. Nature Reviews Gastroenterology and Hepatology. 2014;**11**:506-514. DOI: 10.1038/nrgastro.2014.66 [2] Guarner F, Schaafsma GJ. Probiotics. International Journal of Food Microbiology. 1998;

Antimicrobial Effects of Probiotics and Novel Probiotic-Based Approaches for Infectious Diseases

http://dx.doi.org/10.5772/intechopen.72804

11

[3] Calatayud GA, Suarez JE. A new contribution to the history of probiotics. Beneficial

[4] Snydman DR. The safety of probiotics. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 2008;**46**(Suppl 2):S104-S111.

[5] Sanders ME. Clinical use of probiotics: What physicians need to know. American Family

[7] El Hage R, Hernandez-Sanabria E, Van de Wiele T. Emerging trends in "smart probiotics": Functional consideration for the development of novel health and industrial appli-

[8] Saarela M, Mogensen G, Fonden R, Matto J, Mattila-Sandholm T. Probiotic bacteria: Safety, functional and technological properties. Journal of Biotechnology. 2000;**84**:197-215 [9] Hu HJ, Zhang GQ, Zhang Q, Shakya S, Li ZY. Probiotics prevent *Candida* colonization and invasive fungal sepsis in preterm neonates: A systematic review and meta-analysis of randomized controlled trials. Pediatrics and Neonatology. 2017;**58**:103-110. DOI:

[10] Sinclair A, Xie X, Saab L, Dendukuri N. *Lactobacillus* probiotics in the prevention of diarrhea associated with *Clostridium difficile*: A systematic review and Bayesian hierarchical

[11] Lievin-Le Moal V. A gastrointestinal anti-infectious biotherapeutic agent: The heattreated *Lactobacillus* LB. Therapeutic Advances in Gastroenterology. 2016;**9**:57-75. DOI:

[12] DiRienzo DB. Effect of probiotics on biomarkers of cardiovascular disease: Implications for heart-healthy diets. Nutrition Reviews. 2014;**72**:18-29. DOI: 10.1111/nure.12084 [13] Rodes L, Khan A, Paul A, Coussa-Charley M, Marinescu D, Tomaro-Duchesneau C, et al. Effect of probiotics *Lactobacillus* and *Bifidobacterium* on gut-derived lipopolysaccharides and inflammatory cytokines: An in vitro study using a human colonic microbiota model.

meta-analysis. CMAJ Open. 2016;**4**:E706-E718. DOI: 10.9778/cmajo.20160087

Journal of Microbiology and Biotechnology. 2013;**23**:518-526

[6] Kligler B, Cohrssen A. Probiotics. American Family Physician. 2008;**78**:1073-1078

cations. Frontiers in Microbiology. 2017;**8**:1889. DOI: 10.3389/fmicb.2017.01889

Microbes. 2017;**8**:323-325. DOI: 10.3920/BM2017.x002

discussion S144-151. DOI: 10.1086/523331

Physician. 2008;**78**:1026

10.1016/j.pedneo.2016.06.001

10.1177/1756283X15602831

With respect to the potential risks of probiotics, it is important to conduct population-based surveillance for safety concern.

#### **5. Conclusions**

Probiotics have the ability to restore the imbalance of intestinal microbiota and could act as both prophylactic and adjunctive therapy against candidiasis. Antifungal effect of probiotics is likely due to their interference with *Candida* biofilm development and hyphal differentiation. Safety may be of concern in application, as probiotic strains may, although quite rarely, cause bacteremia, fungemia, and sepsis. Well-designed RCTs are required to address these issues before the routine use of probiotics is recommended.

#### **Acknowledgements**

This project was funded by the National Key Research and Development Program of China (2016YFD0400400), the National Science Foundation of China (31601449), the International Science and Technology Cooperation Program of China (2013DFA32330), the Natural Science Foundation of Zhejiang Province (LY16C200002), and the Food Science and Engineering—the most important discipline of Zhejiang Province (2017SIAR202).

#### **Author details**

Ping Li and Qing Gu\*

\*Address all correspondence to: guqing2002@hotmail.com

Key Laboratory for Food Microbial Technology of Zhejiang Province, College of Food Science and Biotechnology, Zhejiang Gongshang University, Hangzhou, China

#### **References**

**4.3. Transfer of antibiotic resistance**

10 Probiotics - Current Knowledge and Future Prospects

to *Leuconostoc* species and *Pediococcus* species.

issues before the routine use of probiotics is recommended.

most important discipline of Zhejiang Province (2017SIAR202).

\*Address all correspondence to: guqing2002@hotmail.com

surveillance for safety concern.

**5. Conclusions**

**Acknowledgements**

**Author details**

Ping Li and Qing Gu\*

Another major safety concern of theoretical importance is genetic transfer of antibiotic resistance from probiotic strains to pathogenic cells in the gastrointestinal tract [96, 97]. Plasmids with antibiotic-resistance genes, including genes encoding resistance to tetracycline, erythromycin, chloramphenicol, and macrolide-lincosamide-streptogramin, have been found in *L. plantarum*, *L. fermentum*, *L. acidophilus*, and *L. reuteri* strains. *L. plantarum* 5057 exhibited tetracycline resistance, and *L. lactis* was with streptomycin, tetracycline, and chloramphenicol resistances [98–100]. Although the transfer of native *Lactobacillus* plasmids is quite rare, there are some cases, e.g., the antibiotic-resistance plasmids from *Lactococcus* species could transfer

With respect to the potential risks of probiotics, it is important to conduct population-based

Probiotics have the ability to restore the imbalance of intestinal microbiota and could act as both prophylactic and adjunctive therapy against candidiasis. Antifungal effect of probiotics is likely due to their interference with *Candida* biofilm development and hyphal differentiation. Safety may be of concern in application, as probiotic strains may, although quite rarely, cause bacteremia, fungemia, and sepsis. Well-designed RCTs are required to address these

This project was funded by the National Key Research and Development Program of China (2016YFD0400400), the National Science Foundation of China (31601449), the International Science and Technology Cooperation Program of China (2013DFA32330), the Natural Science Foundation of Zhejiang Province (LY16C200002), and the Food Science and Engineering—the

Key Laboratory for Food Microbial Technology of Zhejiang Province, College of Food

Science and Biotechnology, Zhejiang Gongshang University, Hangzhou, China


[14] Messaoudi S, Manai M, Kergourlay G, Prevost H, Connil N, Chobert JM, et al. *Lactobacillus salivarius*: Bacteriocin and probiotic activity. Food Microbiology. 2013;**36**:296-304. DOI: 10.1016/j.fm.2013.05.010

[26] Jiang Q, Stamatova I, Kari K, Meurman JH. Inhibitory activity in vitro of probiotic lactobacilli against oral *Candida* under different fermentation conditions. Beneficial Microbes.

Antimicrobial Effects of Probiotics and Novel Probiotic-Based Approaches for Infectious Diseases

http://dx.doi.org/10.5772/intechopen.72804

13

[27] Machairas N, Pistiki A, Droggiti DI, Georgitsi M, Pelekanos N, Damoraki G, et al. Pre-treatment with probiotics prolongs survival after experimental infection by multidrug-resistant *Pseudomonas aeruginosa* in rodents: An effect on sepsis-induced immunosuppression. International Journal of Antimicrobial Agents. 2015;**45**:376-384. DOI:

[28] Manzoni P, Mostert M, Leonessa ML, Priolo C, Farina D, Monetti C, et al. Oral supplementation with *Lactobacillus casei* subspecies rhamnosus prevents enteric colonization by *Candida* species in preterm neonates: A randomized study. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 2006;**42**:1735-1742.

[29] Mangell P, Lennernas P, Wang M, Olsson C, Ahrne S, Molin G, et al. Adhesive capability of *Lactobacillus plantarum* 299v is important for preventing bacterial translocation in endotoxemic rats. Acta Pathologica, Microbiologica, et Immunologica Scandinavica.

[30] Ruan X, Shi H, Xia G, Xiao Y, Dong J, Ming F, et al. Encapsulated *Bifidobacteria* reduced bacterial translocation in rats following hemorrhagic shock and resuscitation. Nutrition.

[31] Sanchez E, Nieto JC, Boullosa A, Vidal S, Sancho FJ, Rossi G, et al. VSL#3 probiotic treatment decreases bacterial translocation in rats with carbon tetrachloride-induced cirrhosis. Liver International: Official Journal of the International Association for the Study of

[32] Shimizu K, Ogura H, Goto M, Asahara T, Nomoto K, Morotomi M, et al. Synbiotics decrease the incidence of septic complications in patients with severe SIRS: A preliminary report. Digestive Diseases and Sciences. 2009;**54**:1071-1078. DOI: 10.1007/s10620-

[33] Hayakawa M, Asahara T, Ishitani T, Okamura A, Nomoto K, Gando S. Synbiotic therapy reduces the pathological Gram-negative rods caused by an increased acetic acid concentration in the gut. Digestive Diseases and Sciences. 2012;**57**:2642-2649. DOI: 10.1007/

[34] Jain PK, McNaught CE, Anderson AD, MacFie J, Mitchell CJ. Influence of synbiotic containing *Lactobacillus acidophilus* La5, *Bifidobacterium lactis* Bb 12, *Streptococcus thermophilus*, *Lactobacillus bulgaricus* and oligofructose on gut barrier function and sepsis in critically ill patients: A randomised controlled trial. Clinical Nutrition. 2004;**23**:467-475.

[35] Mohan R, Koebnick C, Schildt J, Schmidt S, Mueller M, Possner M, et al. Effects of *Bifidobacterium lactis* Bb12 supplementation on intestinal microbiota of preterm infants: A

2006;**114**:611-618. DOI: 10.1111/j.1600-0463.2006.apm\_369.x

2007;**23**:754-761. DOI: 10.1016/j.nut.2007.07.002

the Liver. 2015;**35**:735-745. DOI: 10.1111/liv.12566

2015;**6**:361-368. DOI: 10.3920/BM2014.0054

10.1016/j.ijantimicag.2014.11.013

DOI: 10.1086/504324

008-0460-2

s10620-012-2201-9

DOI: 10.1016/j.clnu.2003.12.002


[26] Jiang Q, Stamatova I, Kari K, Meurman JH. Inhibitory activity in vitro of probiotic lactobacilli against oral *Candida* under different fermentation conditions. Beneficial Microbes. 2015;**6**:361-368. DOI: 10.3920/BM2014.0054

[14] Messaoudi S, Manai M, Kergourlay G, Prevost H, Connil N, Chobert JM, et al. *Lactobacillus salivarius*: Bacteriocin and probiotic activity. Food Microbiology. 2013;**36**:296-304. DOI:

[15] Johnston BC, Goldenberg JZ, Parkin PC. Probiotics and the prevention of antibioticassociated diarrhea in infants and children. JAMA. 2016;**316**:1484-1485. DOI: 10.1001/

[16] Shida K, Nomoto K. Probiotics as efficient immunopotentiators: Translational role in cancer prevention. The Indian Journal of Medical Research. 2013;**138**:808-814

[17] Ivey KL, Hodgson JM, Kerr DA, Thompson PL, Stojceski B, Prince RL. The effect of yoghurt and its probiotics on blood pressure and serum lipid profile; a randomised controlled trial. Nutrition, Metabolism, and Cardiovascular Diseases. 2015;**25**:46-51. DOI:

[18] Khalesi S, Sun J, Buys N, Jayasinghe R. Effect of probiotics on blood pressure: A systematic review and meta-analysis of randomized, controlled trials. Hypertension.

[19] Yang Y, Xia Y, Chen H, Hong L, Feng J, Yang J, et al. The effect of perioperative probiotics treatment for colorectal cancer: Short-term outcomes of a randomized controlled trial.

[20] Lopez-Siles M, Khan TM, Duncan SH, Harmsen HJ, Garcia-Gil LJ, Flint HJ. Cultured representatives of two major phylogroups of human colonic *Faecalibacterium prausnitzii* can utilize pectin, uronic acids, and host-derived substrates for growth. Applied and

[21] Bunesova V, Lacroix C, Schwab C. Mucin cross-feeding of infant *Bifidobacteria* and

[22] Belzer C, Chia LW, Aalvink S, Chamlagain B, Piironen V, Knol J, et al. Microbial metabolic networks at the mucus layer lead to diet-independent butyrate and vitamin B12 production by intestinal symbionts. mBio. 2017;**8**(5):e00770-17. DOI: 10.1128/mBio.00770-17

[23] Timmerman HM, Koning CJ, Mulder L, Rombouts FM, Beynen AC. Monostrain, multistrain and multispecies probiotics—A comparison of functionality and efficacy. International Journal of Food Microbiology. 2004;**96**:219-233. DOI: 10.1016/j.ijfoodmicro.2004.05.012

[24] Timmerman HM, Niers LE, Ridwan BU, Koning CJ, Mulder L, Akkermans LM, et al. Design of a multispecies probiotic mixture to prevent infectious complications in critically ill patients. Clinical Nutrition. 2007;**26**:450-459. DOI: 10.1016/j.clnu.2007.04.008

[25] Koning CJ, Jonkers DM, Stobberingh EE, Mulder L, Rombouts FM, Stockbrugger RW. The effect of a multispecies probiotic on the intestinal microbiota and bowel movements in healthy volunteers taking the antibiotic amoxicillin. The American Journal of

Gastroenterology. 2008;**103**:178-189. DOI: 10.1111/j.1572-0241.2007.01547.x

Environmental Microbiology. 2012;**78**:420-428. DOI: 10.1128/AEM.06858-11

*Eubacterium hallii*. Microbial Ecology. 2017. DOI: 10.1007/s00248-017-1037-4

2014;**64**:897-903. DOI: 10.1161/HYPERTENSIONAHA.114.03469

Oncotarget. 2016;**7**:8432-8440. DOI: 10.18632/oncotarget.7045

10.1016/j.fm.2013.05.010

12 Probiotics - Current Knowledge and Future Prospects

10.1016/j.numecd.2014.07.012

jama.2016.11838


double-blind, placebo-controlled, randomized study. Journal of Clinical Microbiology. 2006;**44**:4025-4031. DOI: 10.1128/JCM.00767-06

[47] Sharma A, Srivastava S. Anti-*Candida* activity of two-peptide bacteriocins, plantaricins (Pln E/F and J/K) and their mode of action. Fungal Biology. 2014;**118**:264-275. DOI:

Antimicrobial Effects of Probiotics and Novel Probiotic-Based Approaches for Infectious Diseases

http://dx.doi.org/10.5772/intechopen.72804

15

[48] Bommarius B, Jenssen H, Elliott M, Kindrachuk J, Pasupuleti M, Gieren H, et al. Costeffective expression and purification of antimicrobial and host defense peptides in

[49] Gillor O, Etzion A, Riley MA. The dual role of bacteriocins as anti- and probiotics. Applied Microbiology and Biotechnology. 2008;**81**:591-606. DOI: 10.1007/s00253-008-1726-5

[50] Diep DB, Straume D, Kjos M, Torres C, Nes IF. An overview of the mosaic bacteriocin pln loci from *Lactobacillus plantarum*. Peptides. 2009;**30**:1562-1574. DOI: 10.1016/j.peptides.

[51] Valenzuela AS, Ruiz GD, Ben Omar N, Abriouel H, Lopez RL, Canamero MM, et al. Inhibition of food poisoning and pathogenic bacteria by *Lactobacillus plantarum* strain 2.9 isolated from ben saalga, both in a culture medium and in food. Food Control.

[52] Li X, Gu Q, Lou X, Zhang X, Song D, Shen L, et al. Complete genome sequence of the probiotic *Lactobacillus plantarum* strain ZJ316. Genome Announcements. 2013;**1**:e0009413.

[53] Zhu X, Zhao Y, Sun Y, Gu Q. Purification and characterisation of plantaricin ZJ008, a novel bacteriocin against *Staphylococcus* spp. from *Lactobacillus plantarum* ZJ008. Food

[54] Song DF, Zhu MY, Gu Q. Purification and characterization of Plantaricin ZJ5, a new bacteriocin produced by *Lactobacillus plantarum* ZJ5. PLoS One. 2014;**9**:e105549. DOI:

[55] Francavilla R, Miniello V, Magista AM, De Canio A, Bucci N, Gagliardi F, et al. A randomized controlled trial of *Lactobacillus* GG in children with functional abdominal pain.

[56] Al-Sadi R, Nighot P, Guo SH, Al-Omari D, Ma TY. *Lactobacillus Acidophilus* enhancement of intestinal epithelial tight junction barrier is mediated by p38 kinase and toll-like

[57] Grosse C, Scherer J, Koch D, Otto M, Taudte N, Grass G. A new ferrous iron-uptake transporter, EfeU (YcdN), from *Escherichia coli*. Molecular Microbiology. 2006;**62**:120-

[58] Lewis K, Lutgendorff F, Phan V, Soderholm JD, Sherman PM, McKay DM. Enhanced translocation of bacteria across metabolically stressed epithelia is reduced by butyrate.

[59] Wong JM, Jenkins DJ. Carbohydrate digestibility and metabolic effects. The Journal of

Inflammatory Bowel Diseases. 2010;**16**:1138-1148. DOI: 10.1002/ibd.21177

Chemistry. 2014;**165**:216-223. DOI: 10.1016/j.foodchem.2014.05.034

Pediatrics. 2010;**126**:e1445-e1452. DOI: 10.1542/peds.2010-0467

receptor-2 (TLR-2). Gastroenterology. 2016;**150**:S1007-S1007

131. DOI: 10.1111/j.1365-2958.2006.05326.x

Nutrition. 2007;**137**:2539S-2546S

2008;**19**:842-848. DOI: 10.1016/j.foodcont.2007.08.009

DOI: 10.1128/genomeA.00094-13

10.1371/journal.pone.0105549

*Escherichia coli*. Peptides. 2010;**31**:1957-1965. DOI: 10.1016/j.peptides.2010.08.008

10.1016/j.funbio.2013.12.006

2009.05.014


[47] Sharma A, Srivastava S. Anti-*Candida* activity of two-peptide bacteriocins, plantaricins (Pln E/F and J/K) and their mode of action. Fungal Biology. 2014;**118**:264-275. DOI: 10.1016/j.funbio.2013.12.006

double-blind, placebo-controlled, randomized study. Journal of Clinical Microbiology.

[36] Sanaie S, Ebrahimi-Mameghani M, Hamishehkar H, Mojtahedzadeh M, Mahmoodpoor A. Effect of a multispecies probiotic on inflammatory markers in critically ill patients: A randomized, double-blind, placebo-controlled trial. Journal of Research in Medical Sciences: The Official Journal of Isfahan University of Medical Sciences. 2014;**19**:827-833

[37] McNaught CE, Woodcock NP, Anderson AD, MacFie J. A prospective randomised trial of probiotics in critically ill patients. Clinical Nutrition. 2005;**24**:211-219. DOI: 10.1016/j.

[38] Ebrahimi-Mameghani M, Sanaie S, Mahmoodpoor A, Hamishehkar H. Effect of a probiotic preparation (VSL#3) in critically ill patients: A randomized, double-blind, placebocontrolled trial (pilot study). Pakistan Journal of Medical Sciences. 2013;**29**:490-494 [39] Atanassova M, Choiset Y, Dalgalarrondo M, Chobert JM, Dousset X, Ivanova I, et al. Isolation and partial biochemical characterization of a proteinaceous anti-bacteria and anti-yeast compound produced by *Lactobacillus paracasei* subsp. *paracasei* strain M3.

[40] Kanmani P, Satish Kumar R, Yuvaraj N, Paari KA, Pattukumar V, Arul V. Probiotics and its functionally valuable products—A review. Critical Reviews in Food Science and

[41] Li P, Li X, Gu Q, Lou X, Zhang X, Song D, et al. Comparative genomic analysis of *Lactobacillus plantarum* ZJ316 reveals its genetic adaptation and potential probiotic profiles. Journal of Zhejiang University: Science B. 2016. DOI: 10.1631/jzus.B1600176

[42] Li P, Gu Q. Complete genome sequence of *Lactobacillus plantarum* LZ95, a potential probiotic strain producing bacteriocins and B-group vitamin riboflavin. Journal of

[43] Li P, Gu Q, Zhou Q. Complete genome sequence of *Lactobacillus plantarum* LZ206, a potential probiotic strain with antimicrobial activity against food-borne pathogenic microorganisms. Journal of Biotechnology. 2016;**238**:52-55. DOI: 10.1016/j.jbiotec.2016.09.012 [44] Stoianova LG, Ustiugova EA, Netrusov AI. Antibacterial metabolites of lactic acid bacteria: Their diversity and properties. Prikladnaia Biokhimiia i Mikrobiologiia. 2012;**48**:

[45] Kailasapathy K, Chin J. Survival and therapeutic potential of probiotic organisms with reference to *Lactobacillus acidophilus* and *Bifidobacterium* spp. Immunology and Cell

[46] Atassi F, Servin AL. Individual and co-operative roles of lactic acid and hydrogen peroxide in the killing activity of enteric strain *Lactobacillus johnsonii* NCC933 and vaginal strain *Lactobacillus gasseri* KS120.1 against enteric, uropathogenic and vaginosis-associated pathogens. FEMS Microbiology Letters. 2010;**304**:29-38. DOI: 10.1111/j.1574-6968.

2006;**44**:4025-4031. DOI: 10.1128/JCM.00767-06

14 Probiotics - Current Knowledge and Future Prospects

International Journal of Food Microbiology. 2003;**87**:63-73

Nutrition. 2013;**53**:641-658. DOI: 10.1080/10408398.2011.553752

Biotechnology. 2016;**229**:1-2. DOI: 10.1016/j.jbiotec.2016.04.048

Biology. 2000;**78**:80-88. DOI: 10.1046/j.1440-1711.2000.00886.x

clnu.2004.08.008

259-275

2009.01887.x


[60] Rolfe RD. The role of probiotic cultures in the control of gastrointestinal health. The Journal of Nutrition. 2000;**130**:396S-402S

[72] Zaoutis T. Candidemia in children. Current Medical Research and Opinion. 2010;**26**:1761-

Antimicrobial Effects of Probiotics and Novel Probiotic-Based Approaches for Infectious Diseases

http://dx.doi.org/10.5772/intechopen.72804

17

[73] Steinbach WJ. Epidemiology of invasive fungal infections in neonates and children. Clinical Microbiology and Infection: The Official Publication of the European Society of Clinical Microbiology and Infectious Diseases. 2010;**16**:1321-1327. DOI: 10.1111/j.

[74] Hu H, Merenstein DJ, Wang C, Hamilton PR, Blackmon ML, Chen H, et al. Impact of eating probiotic yogurt on colonization by *Candida* species of the oral and vaginal mucosa in HIV-infected and HIV-uninfected women. Mycopathologia. 2013;**176**:175-181. DOI:

[75] Roy A, Chaudhuri J, Sarkar D, Ghosh P, Chakraborty S. Role of enteric supplementation of probiotics on late-onset sepsis by *Candida* species in preterm low birth weight neonates: A randomized, double blind, placebo-controlled trial. North American Journal of

[76] Hatakka K, Ahola AJ, Yli-Knuuttila H, Richardson M, Poussa T, Meurman JH, et al. Probiotics reduce the prevalence of oral candida in the elderly—A randomized controlled trial. Journal of Dental Research. 2007;**86**:125-130. DOI: 10.1177/154405910708600204

[77] Kohler GA, Assefa S, Reid G. Probiotic interference of *Lactobacillus rhamnosus* GR-1 and *Lactobacillus reuteri* RC-14 with the opportunistic fungal pathogen *Candida albicans*. Infectious Diseases in Obstetrics and Gynecology. 2012;**2012**:636474. DOI: 10.1155/2012/

[78] Vilela SF, Barbosa JO, Rossoni RD, Santos JD, Prata MC, Anbinder AL, et al. *Lactobacillus acidophilus* ATCC 4356 inhibits biofilm formation by *C. albicans* and attenuates the experimental candidiasis in *Galleria mellonella*. Virulence. 2015;**6**:29-39. DOI: 10.4161/21505594.

[79] Coman MM, Verdenelli MC, Cecchini C, Silvi S, Orpianesi C, Boyko N, et al. In vitro evaluation of antimicrobial activity of *Lactobacillus rhamnosus* IMC 501((R)), *Lactobacillus paracasei* IMC 502((R)) and SYNBIO((R)) against pathogens. Journal of Applied Micro-

[80] Ujaoney S, Chandra J, Faddoul F, Chane M, Wang J, Taifour L, et al. In vitro effect of over-the-counter probiotics on the ability of *Candida albicans* to form biofilm on denture

[81] Strus M, Kucharska A, Kukla G, Brzychczy-Wloch M, Maresz K, Heczko PB. The in vitro activity of vaginal *Lactobacillus* with probiotic properties against *Candida*. Infectious Diseases in Obstetrics and Gynecology. 2005;**13**:69-75. DOI: 10.1080/10647440400028136

[82] Martinez RC, Franceschini SA, Patta MC, Quintana SM, Candido RC, Ferreira JC, et al. Improved treatment of vulvovaginal candidiasis with fluconazole plus probiotic *Lactobacillus rhamnosus* GR-1 and *Lactobacillus reuteri* RC-14. Letters in Applied Micro-

biology. 2009;**48**:269-274. DOI: 10.1111/j.1472-765X.2008.02477.x

Medical Sciences. 2014;**6**:50-57. DOI: 10.4103/1947-2714.125870

biology. 2014;**117**:518-527. DOI: 10.1111/jam.12544

strips. Journal of Dental Hygiene. 2014;**88**:183-189

1768. DOI: 10.1185/03007995.2010.487796

1469-0691.2010.03288.x

10.1007/s11046-013-9678-4

636474

2014.981486


[72] Zaoutis T. Candidemia in children. Current Medical Research and Opinion. 2010;**26**:1761- 1768. DOI: 10.1185/03007995.2010.487796

[60] Rolfe RD. The role of probiotic cultures in the control of gastrointestinal health. The

[61] Engels C, Ruscheweyh HJ, Beerenwinkel N, Lacroix C, Schwab C. The common gut microbe *Eubacterium hallii* also contributes to intestinal propionate formation. Frontiers

[62] Rakoff-Nahoum S, Paglino J, Eslami-Varzaneh F, Edberg S, Medzhitov R. Recognition of commensal microflora by toll-like receptors is required for intestinal homeostasis. Cell.

[63] Zhang Z, Hinrichs DJ, Lu H, Chen H, Zhong W, Kolls JK. After interleukin-12p40, are interleukin-23 and interleukin-17 the next therapeutic targets for inflammatory bowel disease? International Immunopharmacology. 2007;**7**:409-416. DOI: 10.1016/j.

[64] Badia R, Zanello G, Chevaleyre C, Lizardo R, Meurens F, Martinez P, et al. Effect of *Saccharomyces cerevisiae* var. *Boulardii* and beta-galactomannan oligosaccharide on porcine intestinal epithelial and dendritic cells challenged in vitro with *Escherichia coli* F4

[65] Stier H, Bischoff SC. Influence of *Saccharomyces boulardii* CNCM I-745 on the gut-associated immune system. Clinical and Experimental Gastroenterology. 2016;**9**:269-279. DOI:

[66] Smith IM, Christensen JE, Arneborg N, Jespersen L. Yeast modulation of human dendritic cell cytokine secretion: An in vitro study. PLoS One. 2014;**9**:e96595. DOI: 10.1371/

[67] Ng SC, Hart AL, Kamm MA, Stagg AJ, Knight SC. Mechanisms of action of probiotics: Recent advances. Inflammatory Bowel Diseases. 2009;**15**:300-310. DOI: 10.1002/ibd.20602

[68] Plaza-Diaz J, Gomez-Llorente C, Fontana L, Gil A. Modulation of immunity and inflammatory gene expression in the gut, in inflammatory diseases of the gut and in the liver by probiotics. World Journal of Gastroenterology. 2014;**20**:15632-15649. DOI: 10.3748/

[69] Breyner NM, Michon C, de Sousa CS, Boas PBV, Chain F, Azevedo VA, et al. Microbial anti-inflammatory molecule (MAM) from *Faecalibacterium prausnitzii* shows a protective effect on DNBS and DSS-induced colitis model in mice through inhibition of NF-kappa

B pathway. Frontiers in Microbiology. 2017;**8**:114. DOI: 10.3389/fmicb.2017.00114

[70] Yan F, Polk DB. Probiotic bacterium prevents cytokine-induced apoptosis in intestinal epithelial cells. The Journal of Biological Chemistry. 2002;**277**:50959-50965. DOI: 10.1074/

[71] Wu Q, Liu MC, Yang J, Wang JF, Zhu YH. *Lactobacillus rhamnosus* GR-1 ameliorates *Escherichia coli*-induced inflammation and cell damage via attenuation of ASC-independent NLRP3 inflammasome activation. Applied and Environmental Microbiology. 2015;**82**:

(K88). Veterinary Research. 2012;**43**:4. DOI: 10.1186/1297-9716-43-4

Journal of Nutrition. 2000;**130**:396S-402S

16 Probiotics - Current Knowledge and Future Prospects

in Microbiology. 2016;**7**:713. DOI: 10.3389/fmicb.2016.00713

2004;**118**:229-241. DOI: 10.1016/j.cell.2004.07.002

intimp.2006.09.024

10.2147/CEG.S111003

journal.pone.0096595

wjg.v20.i42.15632

jbc.M207050200

1173-1182. DOI: 10.1128/AEM.03044-15


[83] Kumar S, Bansal A, Chakrabarti A, Singhi S. Evaluation of efficacy of probiotics in prevention of candida colonization in a PICU-a randomized controlled trial. Critical Care Medicine. 2013;**41**:565-572. DOI: 10.1097/CCM.0b013e31826a409c

[95] Lidbeck A, Nord CE, Gustafsson JA, Rafter J. *Lactobacilli*, anticarcinogenic activities and human intestinal microflora. European Journal of Cancer Prevention: The Official

Antimicrobial Effects of Probiotics and Novel Probiotic-Based Approaches for Infectious Diseases

http://dx.doi.org/10.5772/intechopen.72804

19

[96] Egervarn M, Danielsen M, Roos S, Lindmark H, Lindgren S. Antibiotic susceptibility profiles of *Lactobacillus reuteri* and *Lactobacillus fermentum*. Journal of Food Protection.

[97] Egervarn M, Roos S, Lindmark H. Identification and characterization of antibiotic resistance genes in *Lactobacillus reuteri* and *Lactobacillus plantarum*. Journal of Applied

[98] Gevers D, Danielsen M, Huys G, Swings J. Molecular characterization of tet(M) genes in *Lactobacillus* isolates from different types of fermented dry sausage. Applied and

[99] Lin CF, Fung ZF, Wu CL, Chung TC. Molecular characterization of a plasmid-borne (pTC82) chloramphenicol resistance determinant (cat-TC) from *Lactobacillus reuteri* G4.

[100] Tannock GW, Luchansky JB, Miller L, Connell H, Thode-Andersen S, Mercer AA, et al. Molecular characterization of a plasmid-borne (pGT633) erythromycin resistance determinant (ermGT) from *Lactobacillus reuteri* 100-63. Plasmid. 1994;**31**:60-71. DOI: 10.1006/

Journal of the European Cancer Prevention Organisation. 1992;**1**:341-353

Microbiology. 2009;**107**:1658-1668. DOI: 10.1111/j.1365-2672.2009.04352.x

Environmental Microbiology. 2003;**69**:1270-1275

Plasmid. 1996;**36**:116-124. DOI: 10.1006/plas.1996.0039

2007;**70**:412-418

plas.1994.1007


[95] Lidbeck A, Nord CE, Gustafsson JA, Rafter J. *Lactobacilli*, anticarcinogenic activities and human intestinal microflora. European Journal of Cancer Prevention: The Official Journal of the European Cancer Prevention Organisation. 1992;**1**:341-353

[83] Kumar S, Bansal A, Chakrabarti A, Singhi S. Evaluation of efficacy of probiotics in prevention of candida colonization in a PICU-a randomized controlled trial. Critical Care

[84] Li D, Li Q, Liu C, Lin M, Li X, Xiao X, et al. Efficacy and safety of probiotics in the treatment of *Candida*-associated stomatitis. Mycoses. 2014;**57**:141-146. DOI: 10.1111/

[85] Kraft-Bodi E, Jorgensen MR, Keller MK, Kragelund C, Twetman S. Effect of probiotic bacteria on oral *Candida* in frail elderly. Journal of Dental Research. 2015;**94**:181S-186S. DOI:

[86] Kheradmand E, Rafii F, Yazdi MH, Sepahi AA, Shahverdi AR, Oveisi MR. The antimicrobial effects of selenium nanoparticle-enriched probiotics and their fermented broth against *Candida albicans*. Daru: Journal of Faculty of Pharmacy, Tehran University of

[87] Murzyn A, Krasowska A, Stefanowicz P, Dziadkowiec D, Lukaszewicz M. Capric acid secreted by *S. boulardii* inhibits *C. albicans* filamentous growth, adhesion and biofilm

[88] Kunz AN, Noel JM, Fairchok MP. Two cases of *Lactobacillus* bacteremia during probiotic treatment of short gut syndrome. Journal of Pediatric Gastroenterology and Nutrition.

[89] Cannon JP, Lee TA, Bolanos JT, Danziger LH. Pathogenic relevance of *Lactobacillus*: A retrospective review of over 200 cases. European Journal of Clinical Microbiology & Infectious Diseases: Official Publication of the European Society of Clinical Microbiology.

[90] Land MH, Rouster-Stevens K, Woods CR, Cannon ML, Cnota J, Shetty AK. *Lactobacillus* sepsis associated with probiotic therapy. Pediatrics. 2005;**115**:178-181. DOI: 10.1542/

[91] Mackay AD, Taylor MB, Kibbler CC, Hamilton-Miller JM. *Lactobacillus endocarditis* caused by a probiotic organism. Clinical Microbiology and Infection: The Official Publication of the European Society of Clinical Microbiology and Infectious Diseases. 1999;**5**:290-292

[92] Meini S, Laureano R, Fani L, Tascini C, Galano A, Antonelli A, et al. Breakthrough *Lactobacillus rhamnosus* GG bacteremia associated with probiotic use in an adult patient with severe active ulcerative colitis: Case report and review of the literature. Infection.

[93] Salminen MK, Tynkkynen S, Rautelin H, Saxelin M, Vaara M, Ruutu P, et al. *Lactobacillus* bacteremia during a rapid increase in probiotic use of *Lactobacillus rhamnosus* GG in Finland. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases

[94] Gorbach SL, Goldin BR. The intestinal microflora and the colon cancer connection.

formation. PLoS One. 2010;**5**:e12050. DOI: 10.1371/journal.pone.0012050

Medicine. 2013;**41**:565-572. DOI: 10.1097/CCM.0b013e31826a409c

Medical Sciences. 2014;**22**:48. DOI: 10.1186/2008-2231-22-48

2005;**24**:31-40. DOI: 10.1007/s10096-004-1253-y

2015;**43**:777-781. DOI: 10.1007/s15010-015-0798-2

Society of America. 2002;**35**:1155-1160. DOI: 10.1086/342912

Reviews of Infectious Diseases. 1990;**12**(Suppl 2):S252-S261

myc.12116

2004;**38**:457-458

peds.2004-2137

10.1177/0022034515595950

18 Probiotics - Current Knowledge and Future Prospects


**Chapter 2**

**Provisional chapter**

**A Network of Physiological Interactions Modulating GI**

The gastrointestinal surface is in constant interaction with various exogenous molecules. Exogenous components are discriminated in the GI context, as good, in case of nutrients and fibers, and bad, when they negatively affect host integrity. During this tolerogenic process, they also train the host's immune system. The immune system is a morphophysiologic unit driven by immune cells with the assistance of commensal organisms. Several species of commensal microorganisms have been used for centuries as probiotics due to their beneficial effects on human health. Lowering local levels of pro-inflammatory cytokines has a systemic effect, which is one of the fundamental characteristics associated with probiotics. Still, the primary mechanisms wiring those regulatory circuits as a unit remain unclear. Modulation of the innate immune system, via regulation of inflammasome assembly is emerging as a critical driver of this interaction. Stimulation of toll like receptors (TLR) and inner cell sensors like NLRP3 connect probiotics with essential host systems. In this context, the mTOR-regulated circuits, an intricate network modulating a cascade of protein phosphorylations, could be an important channel connecting host

**Keywords:** *Lactobacillus*, inflammasome, caspase-1, mechanistic target of rapamycin

(mTOR), insulin resistance, adipogenesis, type 2 diabetes, cancer

**A Network of Physiological Interactions Modulating GI** 

DOI: 10.5772/intechopen.72656

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

Probiotics are live microorganisms which when administered in adequate amounts confer a health benefit on the host, as defined by the World Health Organization [1]. This is an extremely

**Homeostasis: Probiotics, Inflammasome, mTOR**

**Homeostasis: Probiotics, Inflammasome, mTOR**

Danielle N. Kling, Leandro D. Teixeira,

Danielle N. Kling, Leandro D. Teixeira,

http://dx.doi.org/10.5772/intechopen.72656

metabolism and probiotics crosstalk.

**1. Overview of probiotics**

**1.1. History and use**

**Abstract**

Evon M. DeBose-Scarlett and Claudio F. Gonzalez

Evon M. DeBose-Scarlett and Claudio F. Gonzalez

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

**Provisional chapter**

#### **A Network of Physiological Interactions Modulating GI Homeostasis: Probiotics, Inflammasome, mTOR Homeostasis: Probiotics, Inflammasome, mTOR**

**A Network of Physiological Interactions Modulating GI** 

DOI: 10.5772/intechopen.72656

Danielle N. Kling, Leandro D. Teixeira, Evon M. DeBose-Scarlett and Claudio F. Gonzalez Evon M. DeBose-Scarlett and Claudio F. Gonzalez Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.72656

Danielle N. Kling, Leandro D. Teixeira,

#### **Abstract**

The gastrointestinal surface is in constant interaction with various exogenous molecules. Exogenous components are discriminated in the GI context, as good, in case of nutrients and fibers, and bad, when they negatively affect host integrity. During this tolerogenic process, they also train the host's immune system. The immune system is a morphophysiologic unit driven by immune cells with the assistance of commensal organisms. Several species of commensal microorganisms have been used for centuries as probiotics due to their beneficial effects on human health. Lowering local levels of pro-inflammatory cytokines has a systemic effect, which is one of the fundamental characteristics associated with probiotics. Still, the primary mechanisms wiring those regulatory circuits as a unit remain unclear. Modulation of the innate immune system, via regulation of inflammasome assembly is emerging as a critical driver of this interaction. Stimulation of toll like receptors (TLR) and inner cell sensors like NLRP3 connect probiotics with essential host systems. In this context, the mTOR-regulated circuits, an intricate network modulating a cascade of protein phosphorylations, could be an important channel connecting host metabolism and probiotics crosstalk.

**Keywords:** *Lactobacillus*, inflammasome, caspase-1, mechanistic target of rapamycin (mTOR), insulin resistance, adipogenesis, type 2 diabetes, cancer

#### **1. Overview of probiotics**

#### **1.1. History and use**

Probiotics are live microorganisms which when administered in adequate amounts confer a health benefit on the host, as defined by the World Health Organization [1]. This is an extremely

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

broad definition that encompasses fungal and other eukaryotic species, as well as bacteria. In practice, however, bacterial probiotics receive the most attention. Bacterial probiotics can be found as various supplements and food additives in products such as pills and yogurts [2]. The benefits of probiotic supplements have been recognized for centuries, long before it was understood that the living microorganisms in the supplement provided the benefit. Fermented milk products were used as a treatment for intestinal discomfort in the Roman empire, and ancient Chinese scholars recommended fecal transplant to combat diarrhea [3]. Today, probiotics are often prescribed by gastroenterologists and GI surgeons to help alleviate irritable bowel syndrome, pouchitis, and functional diarrhea, however the potential applications of probiotics in other systems is gaining notice [4]. Yogurt and other fermented milk products as well as probiotic drink mixes are commonly used forms of probiotic supplements today [4].

Strains of the genera *Bifidobacterium* and *Lactobacillus* are the most common bacteria studied and used as probiotics, however *Enterococcus, Streptococcus, Leuconostoc, Bacillus*, and even the yeast *Saccharomyces boulardii* have been used [5, 6]. Knowledge of both the species and strain of bacteria is important in the study and use of probiotics as different strains can produce varying effects on the host. For instance, *Escherichia coli* Nessile 1917 is a beneficial probiotic while *E. coli* 0157:H7 is a deadly pathogen [2, 5]. Sources of probiotics vary. Probiotic bacteria are commonly found in fermented milk products, which lactic acid producing bacteria are essential to the production of, and they have also been isolated from stool samples of healthy individuals [5].

> Probiotics can also inhibit the growth of pathogens in other ways. *Lactobacillus delbrueckii* can bind iron to its surface, making it unavailable to pathogens, many of which need iron to survive [6]. Probiotics may also benefit the host by reducing the ability of pathogens to diffuse across epithelial cell barriers: strains of *Lactobacillus* show an ability to increase intestinal barrier function. Recent research has documented an increase in the levels of claudin-1 and goblet cells seen in healthy rats as well as in *Lactobacillus johnsonii* fed animals, suggesting that one aspect of the bacteria's role in the gut is to strengthen the barrier function to prevent a leaky gut and maintain a high level of mucin production to protect the gut epithelial cells [15]. *Lactobacillus johnsonii* also appeared to increase the expression of inflammatory chemokines, including CCL20 (MIP3A), CXCL8 (IL-8), and CXCL10 (IP10) [16]. This result may indicate that exposure to beneficial *Lactobacillus* primes the gut immune system so that it is resistant to overwhelming inflammation in the face of later insults [16]. An increase in Paneth cells, immune cells in intestinal crypts, was also demonstrated in *Lactobacillus* fed animals [16]. Overall, probiotic bacteria, many in the genus *Lactobacillus*, can play an important role in

> **Figure 1.** Schematic of possible mechanisms of probiotic interactions with molecules in the intestinal lumen as well as

A Network of Physiological Interactions Modulating GI Homeostasis: Probiotics, Inflammasome…

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23

Probiotics can exert their positive effects on the host by producing vitamins or other materials useful to the host: *Bifidobacterium adolescentis* and *B. pseudocatenulatum* produce B vitamins including B1, B2, B3, B6, B8, B9, and B12 [6]. Probiotics may also increase the availability of nutrients already present in foods. Lactic acid bacteria increase the amount of available folic acid in fermented milk products [9]. The positive effects of Lactobacilli may also result from

defending the gastrointestinal tract from pathogenic organisms.

host epithelial cells.

#### **1.2. Mechanisms of action**

Probiotics can have a wide array of beneficial effects on their host organism (**Figure 1**). One way in which probiotics can benefit the host is to simply prevent or reduce the probability of infection by pathogenic organisms. By forming aggregates with intestinal pathogens, probiotics can reduce the ability of these pathogens to adhere to the intestinal mucosa and initiate infection [7]. *Saccharomyces boulardii*, *Lactobacillus gasseri* 4B2, and *Lactobacillus coryniformis* DSM 20001<sup>T</sup> have shown the ability to aggregate with pathogenic strains of *E. coli* (serogroup 0157:H7, and serogroup K88, respectively) [7, 8]. Probiotic bacteria can also increase mucin production in the gut, further reducing ability of pathogens to adhere to and infect host epithelial cells [9]. *E. coli* Nessile 1917 can upregulate the production of MUC2 and MUC3, the primary mucins present in the human colon [10]. Probiotic bacteria often have the ability to produce molecules damaging to pathogens, protecting the host organism by killing or inhibiting the activity of pathogenic bacteria. Several *Lactobacillus* strains produce antimicrobial bacteriocins, some examples include acidocin produced by *Lactobacillus acidophilus*, and sakacin produced by *Lactobacillus sakei* [11, 12]. These molecules may help the host maintain gut homeostasis by regulating the gut bacterial community. Several *Lactobacillus* species can inhibit the growth of *Clostridium difficile* or *C. perfringens* through the production of organic acids, and *Lactobacillus plantarum* LPAL and *Bifidobacterium animalis* ssp. *lactis* BLC1 produce some unknown bactericidal compounds or bacteriocins that inhibit both species [13]. Beneficial gut bacteria can also induce host immune cells to produce defenses against pathogens. Gut bacteria stimulate the production of an antibacterial, peptidoglycan-binding lectin in mice and in humans [14].

A Network of Physiological Interactions Modulating GI Homeostasis: Probiotics, Inflammasome… http://dx.doi.org/10.5772/intechopen.72656 23

broad definition that encompasses fungal and other eukaryotic species, as well as bacteria. In practice, however, bacterial probiotics receive the most attention. Bacterial probiotics can be found as various supplements and food additives in products such as pills and yogurts [2]. The benefits of probiotic supplements have been recognized for centuries, long before it was understood that the living microorganisms in the supplement provided the benefit. Fermented milk products were used as a treatment for intestinal discomfort in the Roman empire, and ancient Chinese scholars recommended fecal transplant to combat diarrhea [3]. Today, probiotics are often prescribed by gastroenterologists and GI surgeons to help alleviate irritable bowel syndrome, pouchitis, and functional diarrhea, however the potential applications of probiotics in other systems is gaining notice [4]. Yogurt and other fermented milk products as well as probiotic drink mixes are commonly used forms of probiotic supplements today [4].

Strains of the genera *Bifidobacterium* and *Lactobacillus* are the most common bacteria studied and used as probiotics, however *Enterococcus, Streptococcus, Leuconostoc, Bacillus*, and even the yeast *Saccharomyces boulardii* have been used [5, 6]. Knowledge of both the species and strain of bacteria is important in the study and use of probiotics as different strains can produce varying effects on the host. For instance, *Escherichia coli* Nessile 1917 is a beneficial probiotic while *E. coli* 0157:H7 is a deadly pathogen [2, 5]. Sources of probiotics vary. Probiotic bacteria are commonly found in fermented milk products, which lactic acid producing bacteria are essential to the production of, and they have also been isolated from stool samples of healthy

Probiotics can have a wide array of beneficial effects on their host organism (**Figure 1**). One way in which probiotics can benefit the host is to simply prevent or reduce the probability of infection by pathogenic organisms. By forming aggregates with intestinal pathogens, probiotics can reduce the ability of these pathogens to adhere to the intestinal mucosa and initiate infection [7]. *Saccharomyces boulardii*, *Lactobacillus gasseri* 4B2, and *Lactobacillus coryniformis* DSM 20001<sup>T</sup> have shown the ability to aggregate with pathogenic strains of *E. coli* (serogroup 0157:H7, and serogroup K88, respectively) [7, 8]. Probiotic bacteria can also increase mucin production in the gut, further reducing ability of pathogens to adhere to and infect host epithelial cells [9]. *E. coli* Nessile 1917 can upregulate the production of MUC2 and MUC3, the primary mucins present in the human colon [10]. Probiotic bacteria often have the ability to produce molecules damaging to pathogens, protecting the host organism by killing or inhibiting the activity of pathogenic bacteria. Several *Lactobacillus* strains produce antimicrobial bacteriocins, some examples include acidocin produced by *Lactobacillus acidophilus*, and sakacin produced by *Lactobacillus sakei* [11, 12]. These molecules may help the host maintain gut homeostasis by regulating the gut bacterial community. Several *Lactobacillus* species can inhibit the growth of *Clostridium difficile* or *C. perfringens* through the production of organic acids, and *Lactobacillus plantarum* LPAL and *Bifidobacterium animalis* ssp. *lactis* BLC1 produce some unknown bactericidal compounds or bacteriocins that inhibit both species [13]. Beneficial gut bacteria can also induce host immune cells to produce defenses against pathogens. Gut bacteria stimulate the production of an antibacterial, peptidoglycan-binding lectin

individuals [5].

**1.2. Mechanisms of action**

22 Probiotics - Current Knowledge and Future Prospects

in mice and in humans [14].

**Figure 1.** Schematic of possible mechanisms of probiotic interactions with molecules in the intestinal lumen as well as host epithelial cells.

Probiotics can also inhibit the growth of pathogens in other ways. *Lactobacillus delbrueckii* can bind iron to its surface, making it unavailable to pathogens, many of which need iron to survive [6]. Probiotics may also benefit the host by reducing the ability of pathogens to diffuse across epithelial cell barriers: strains of *Lactobacillus* show an ability to increase intestinal barrier function. Recent research has documented an increase in the levels of claudin-1 and goblet cells seen in healthy rats as well as in *Lactobacillus johnsonii* fed animals, suggesting that one aspect of the bacteria's role in the gut is to strengthen the barrier function to prevent a leaky gut and maintain a high level of mucin production to protect the gut epithelial cells [15]. *Lactobacillus johnsonii* also appeared to increase the expression of inflammatory chemokines, including CCL20 (MIP3A), CXCL8 (IL-8), and CXCL10 (IP10) [16]. This result may indicate that exposure to beneficial *Lactobacillus* primes the gut immune system so that it is resistant to overwhelming inflammation in the face of later insults [16]. An increase in Paneth cells, immune cells in intestinal crypts, was also demonstrated in *Lactobacillus* fed animals [16]. Overall, probiotic bacteria, many in the genus *Lactobacillus*, can play an important role in defending the gastrointestinal tract from pathogenic organisms.

Probiotics can exert their positive effects on the host by producing vitamins or other materials useful to the host: *Bifidobacterium adolescentis* and *B. pseudocatenulatum* produce B vitamins including B1, B2, B3, B6, B8, B9, and B12 [6]. Probiotics may also increase the availability of nutrients already present in foods. Lactic acid bacteria increase the amount of available folic acid in fermented milk products [9]. The positive effects of Lactobacilli may also result from the bacterial production of esterases. These enzymes are produced by Lactobacilli and have the ability to release beneficial phenolic compounds, such as ferulic acid and caffeic acid, from food molecules [17]. *Lactobacillus johnsonii* N6.2, a strain associated with diabetes resistance in BioBreeding diabetes prone and diabetes resistant rats, produces two ferulic acid esterases that cleave ethyl ferulate and chlorogenic acid [17]. Other small molecules increased by probiotic bacteria can include free amino acids, and short chain fatty acids such as lactic acid, propionic acid, and butyric acid, which can be used by host cells for energy [9]. Some strains of *Lactobacillus* can produce hydrogen peroxide, which is beneficial to the gastrointestinal tract when present in small amounts [18]. In the case of host lactose intolerance, some strains of lactic acid bacteria, *Streptococcus thermophilus*, and *Lactobacillus bulgaricus* can aid in the host's digestion of lactose by supplementing host lactase with their own [9]. *Lactobacillus* species can also increase the nutritional value of various food products. Fermentation with several *Lactobacillus* strains increased the dietary phenol available in cereal grains by a considerable amount [19]. Through both the synthesis and the breakdown of various substances, probiotics can improve host nutrition.

gut. Apple juice fermented with *Lactobacillus* species showed the ability to inhibit *Helicobacter pylori in vitro*, but did not negatively affect other positive GI bacteria [26]. This further shows the ability some probiotics have to ameliorate disease-induced tissue damage and regulate

A Network of Physiological Interactions Modulating GI Homeostasis: Probiotics, Inflammasome…

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25

Probiotic supplements are no cure-all for gastrointestinal maladies, however. Assorted studies have reported little to no benefit of probiotics in the treatment of other gastrointestinal diseases. *Lactobacillus* probiotics were not shown to be an effective treatment in helping patients with Crohn's disease stay in remission [27]. In a clinical trial involving women with irritable bowel syndrome, treatment with probiotics was not more effective than the administration of

On the other hand, there is also a wealth of research showing probiotics to have benefits in areas of the body besides the adult gut. The importance of an individual's microbiome is evident even before birth, therefore the prenatal and neonatal use of probiotics is an important consideration in infant health. The systemic benefits of probiotics can be transferred from mother to infant. In a study on allergies, a probiotic combination taken by an allergic mother, consisting of *Lactobacillus rhamnosus* GG and *Bifidobacterium lactis* Bb12, decreased the probability of sensitization in breastfed infants, possibly by increasing the concentration of the anti-inflammatory cytokine transforming growth factor-beta 2 (TGF-β2) in breast milk [29]. Here we see the ability of a probiotic to induce immune changes in one organism that can be

Certain strains of bacteria have also been shown to reduce the negative effects of oral infections. In a study involving mice that were intubated with *Lactobacillus gasseri* SBT2055 and then infected orally with *Porphyromonas gingivalis*, the intubated mice showed less alveolar bone loss and better maintenance of the periodontal ligament than non-intubated mice [30]. In this case, pretreatment with probiotics helped prevent oral damage from infection. Probiotics may also help maintain or improve liver health. A probiotic mixture containing *Bifidobacterium* and *Lactobacillus* species reduced weight gain, maintained intestinal barrier function, and reduced liver inflammation in rats fed an inflammation-inducing high fat diet [31]. Another study using various *Bifidobacterium* strains corroborated these findings. *B. pseudocatenulatum* LI09 and *B. catenulatum* LI10 showed the ability to reduce D-GalN-induced liver damage and serum levels of inflammatory cytokines in rats [32]. Fang et al. found that supplementation with probiotics reduced levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST), improved liver necrosis and inflammatory cell infiltration, reduced bacterial translocation to mesenteric lymph nodes, and reduced levels of interleukin 1β, macrophage inflammatory protein 1α, monocyte chemoattractant protein 1, and macrophage colony-stim-

Probiotics have been used for centuries around the globe to improve health and treat disease. Although they are most commonly used to treat gastrointestinal diseases, they can exert positive effects on the health of the entire host organism. Although there has been much research elucidating how probiotics benefit their host and what benefits they actually provide, there is

still much to be discovered about the many potential benefits of probiotics.

the gut microbiota.

ulating factor in rats [32].

a placebo in reducing IBS symptom severity [28].

transmitted and positively affect the health of another.

Probiotics have also shown promise in the area of cancer research. *Lactobacillus casei* and *L. rhamnosus* GG can reduce invasion in colon cancer cells, a key property in preventing metastasis [20]. Levels of matrix metalloproteinases, implicated in cell invasion, can be responsive to probiotic treatment: *Lactobacillus acidophilus* and *L. rhamnosus* GG can decrease the expression of matrix metalloproteinase-9 by increasing the expression of the tissue inhibitor of metalloproteinases [20]. Treatment with kefir reduces the viability of colon cancer cell lines by inducing apoptosis and the proliferation of colon cancer cell lines by arresting the cell cycle in the G1 phase [21]. These results suggest that probiotics may be useful in the treatment or prevention of some cancers.

#### **1.3. Health benefits**

Probiotics are commonly used for gastrointestinal complaints and issues, and there has been extensive research on the benefits of probiotics in this body system. Modern research often supports the old assertions that consumption of probiotics is beneficial to gastrointestinal health. Probiotic supplements have shown efficacy in treating certain intestinal disorders in animal models and in humans. Patients in remission from pouchitis who received probiotic treatment in the form of a bacterial supplement called VSL#3 showed increased *Bifidobacterium* and *Lactobacillus* diversity compared to patients receiving a placebo treatment [22]. *Bifidobacterium* and *Lactobacillus* are commonly regarded as beneficial members of the gut microbiota [23]. VSL#3 was also found to reduce the frequency of pouchitis recurrence [24]. This provides support for the use of probiotics in the treatment of GI diseases. A fermented soy probiotic mixture was shown to provide multiple gastrointestinal health benefits to rats with induced colitis. Rats fed the probiotic mixture of *Bifidobacterium longum* and *Lactobacillus helveticus* 416 had no colon damage, ulcers, or swelling, compared to rats who did not receive the probiotic supplement [25]. The rats receiving the probiotic also showed increased intestinal *Lactobacillus* and *Bifidobacterium* populations [25]. Supplementation with probiotics can help adjust the gut microbiota, and this likely plays a role in the effects of diseases of the gut. Apple juice fermented with *Lactobacillus* species showed the ability to inhibit *Helicobacter pylori in vitro*, but did not negatively affect other positive GI bacteria [26]. This further shows the ability some probiotics have to ameliorate disease-induced tissue damage and regulate the gut microbiota.

the bacterial production of esterases. These enzymes are produced by Lactobacilli and have the ability to release beneficial phenolic compounds, such as ferulic acid and caffeic acid, from food molecules [17]. *Lactobacillus johnsonii* N6.2, a strain associated with diabetes resistance in BioBreeding diabetes prone and diabetes resistant rats, produces two ferulic acid esterases that cleave ethyl ferulate and chlorogenic acid [17]. Other small molecules increased by probiotic bacteria can include free amino acids, and short chain fatty acids such as lactic acid, propionic acid, and butyric acid, which can be used by host cells for energy [9]. Some strains of *Lactobacillus* can produce hydrogen peroxide, which is beneficial to the gastrointestinal tract when present in small amounts [18]. In the case of host lactose intolerance, some strains of lactic acid bacteria, *Streptococcus thermophilus*, and *Lactobacillus bulgaricus* can aid in the host's digestion of lactose by supplementing host lactase with their own [9]. *Lactobacillus* species can also increase the nutritional value of various food products. Fermentation with several *Lactobacillus* strains increased the dietary phenol available in cereal grains by a considerable amount [19]. Through both the synthesis and the breakdown of various substances, probiotics

Probiotics have also shown promise in the area of cancer research. *Lactobacillus casei* and *L. rhamnosus* GG can reduce invasion in colon cancer cells, a key property in preventing metastasis [20]. Levels of matrix metalloproteinases, implicated in cell invasion, can be responsive to probiotic treatment: *Lactobacillus acidophilus* and *L. rhamnosus* GG can decrease the expression of matrix metalloproteinase-9 by increasing the expression of the tissue inhibitor of metalloproteinases [20]. Treatment with kefir reduces the viability of colon cancer cell lines by inducing apoptosis and the proliferation of colon cancer cell lines by arresting the cell cycle in the G1 phase [21]. These results suggest that probiotics may be useful in the treatment

Probiotics are commonly used for gastrointestinal complaints and issues, and there has been extensive research on the benefits of probiotics in this body system. Modern research often supports the old assertions that consumption of probiotics is beneficial to gastrointestinal health. Probiotic supplements have shown efficacy in treating certain intestinal disorders in animal models and in humans. Patients in remission from pouchitis who received probiotic treatment in the form of a bacterial supplement called VSL#3 showed increased *Bifidobacterium* and *Lactobacillus* diversity compared to patients receiving a placebo treatment [22]. *Bifidobacterium* and *Lactobacillus* are commonly regarded as beneficial members of the gut microbiota [23]. VSL#3 was also found to reduce the frequency of pouchitis recurrence [24]. This provides support for the use of probiotics in the treatment of GI diseases. A fermented soy probiotic mixture was shown to provide multiple gastrointestinal health benefits to rats with induced colitis. Rats fed the probiotic mixture of *Bifidobacterium longum* and *Lactobacillus helveticus* 416 had no colon damage, ulcers, or swelling, compared to rats who did not receive the probiotic supplement [25]. The rats receiving the probiotic also showed increased intestinal *Lactobacillus* and *Bifidobacterium* populations [25]. Supplementation with probiotics can help adjust the gut microbiota, and this likely plays a role in the effects of diseases of the

can improve host nutrition.

24 Probiotics - Current Knowledge and Future Prospects

or prevention of some cancers.

**1.3. Health benefits**

Probiotic supplements are no cure-all for gastrointestinal maladies, however. Assorted studies have reported little to no benefit of probiotics in the treatment of other gastrointestinal diseases. *Lactobacillus* probiotics were not shown to be an effective treatment in helping patients with Crohn's disease stay in remission [27]. In a clinical trial involving women with irritable bowel syndrome, treatment with probiotics was not more effective than the administration of a placebo in reducing IBS symptom severity [28].

On the other hand, there is also a wealth of research showing probiotics to have benefits in areas of the body besides the adult gut. The importance of an individual's microbiome is evident even before birth, therefore the prenatal and neonatal use of probiotics is an important consideration in infant health. The systemic benefits of probiotics can be transferred from mother to infant. In a study on allergies, a probiotic combination taken by an allergic mother, consisting of *Lactobacillus rhamnosus* GG and *Bifidobacterium lactis* Bb12, decreased the probability of sensitization in breastfed infants, possibly by increasing the concentration of the anti-inflammatory cytokine transforming growth factor-beta 2 (TGF-β2) in breast milk [29]. Here we see the ability of a probiotic to induce immune changes in one organism that can be transmitted and positively affect the health of another.

Certain strains of bacteria have also been shown to reduce the negative effects of oral infections. In a study involving mice that were intubated with *Lactobacillus gasseri* SBT2055 and then infected orally with *Porphyromonas gingivalis*, the intubated mice showed less alveolar bone loss and better maintenance of the periodontal ligament than non-intubated mice [30]. In this case, pretreatment with probiotics helped prevent oral damage from infection. Probiotics may also help maintain or improve liver health. A probiotic mixture containing *Bifidobacterium* and *Lactobacillus* species reduced weight gain, maintained intestinal barrier function, and reduced liver inflammation in rats fed an inflammation-inducing high fat diet [31]. Another study using various *Bifidobacterium* strains corroborated these findings. *B. pseudocatenulatum* LI09 and *B. catenulatum* LI10 showed the ability to reduce D-GalN-induced liver damage and serum levels of inflammatory cytokines in rats [32]. Fang et al. found that supplementation with probiotics reduced levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST), improved liver necrosis and inflammatory cell infiltration, reduced bacterial translocation to mesenteric lymph nodes, and reduced levels of interleukin 1β, macrophage inflammatory protein 1α, monocyte chemoattractant protein 1, and macrophage colony-stimulating factor in rats [32].

Probiotics have been used for centuries around the globe to improve health and treat disease. Although they are most commonly used to treat gastrointestinal diseases, they can exert positive effects on the health of the entire host organism. Although there has been much research elucidating how probiotics benefit their host and what benefits they actually provide, there is still much to be discovered about the many potential benefits of probiotics.

## **2. The effects of probiotics on the inflammasome**

#### **2.1. Inflammasome: the interface between detection and response in inflammation**

TLRs expressed on cell membrane are TLR1, TLR2, TLR4, TLR5, TLR6, TLR10, TLR11 and TLR12, whereas TLR3, TLR7, TLR8, TLR9 and TLR13 are expressed on endosomal membrane [43]. Each TLR specifically binds to microbial molecules, triggering a cascade of signals that result in the transcription and production of pro-inflammatory cytokines and chemokines. TLR4 is one of the most studied TLRs due its ability to detect lipopolysaccharide (LPS), leading to the activation of both myeloid differentiation antigen 88 (MyD88)-dependent and MyD88-independent pathways [44]. Downstream, MyD88 is responsible for the activation of the master transcriptional regulators MAPK and NF-κB, which increase transcriptional expression of IL-1β, IL-6, IL-8 and IL-18 [45]. Like TLRs, NLRs can sense different molecules and trigger an inflammatory response. NLRs also have a structure composed of three main domains: caspase recruitment domain (CARD) or pyrin domain (PYR) at N-terminal; the highly conserved NATCH domain, a nucleotide-binding domain (also called as NBD); and leucine-rich repeats (LRR) at the C-terminal [46]. Based on the N-terminal domain, NLRs are subdivided into 8 sub-families (**Figure 2**). The LRRs are responsible for microbial molecule detection, whereas the CARD and PYD domains are responsible for homotypic and heterotypic interactions of NLRs with downstream molecules, such as procaspase, directly or via the adaptor molecule, apoptotic-associated speck like protein (ASC) [47].

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Once epithelial cells recognize PAMPs or DAMPs, many different responses can be triggered in order to eliminate the source of those molecules. One well-known response against pathogens is called the inflammasome. Inflammasomes are a multiprotein complex formed in response to PAMPs and DAMPs, resulting in the activation of caspase-1 (canonical pathways) or caspase-11 (non-canonical pathway) [48]. NLRs located in the cytosol act as sensors of these microbial molecules, leading to the activation of the inflammasome complex. The inflammasome is basically composed by the NLR family members, which may contain the PYR domain or just the CARD, and by the adapter ASC. ASC has both CARD and PYD domains, and the association between ASC and CARD-containing NLRs recruits caspase-1 via homotypic interactions [49]. Despite around 23 NLR genes having been identified to date, only some of them can form oligomeric complexes which end up in the post-translational activation of caspases [50]. The hallmark of the inflammasome is the recruitment of caspase-1 in the canonical pathway, which is further released and subsequently activated via auto cleavage. Active caspase-1 can cleave and activate more than 70 substrates. This sequential process will finally release active caspase-1 to activate the IL-1β cytokine and gasdermin-D to promote adaptive and humoral immunity (**Figure 2**) [51]. In the non-canonical pathway, cleavage and activation of interleukins can also occur via caspase-4/caspase-5 (humans) or caspase-11 (rodents) [52]. Despite the fact that caspase-1 is a protein that plays an important role in many different pathways, one of the most studied ones is pyroptosis, which is a cell death caused by inflammation in response to microbial infections or nonmicrobial stimuli [53]. In pyroptosis, caspase-1 is activated through inflammasome assembly and its active form can then cleave gasdermin-D (GSDMD) at Asp276, which generates the N-terminal cleavage product (GSDMD-NT) triggering pyroptosis and cell death. GSDMD-NT has the ability to form pores on the cell membrane, leading to cell leakage and the release of pro-inflammatory cytokines [54]. Moreover, active

**2.3. Inflammasome assembly**

Inflammation is a complex immune response to many different insults, such as pathogens, cell death, and chemicals, which promotes survival during infectious diseases or injuries, as well as maintains tissue homeostasis. When an insult is identified, a cascade of signals is triggered, concluding in the recruitment of neutrophils and macrophages, which have the ability to produce several cytokines and chemokines. Despite the beneficial effects of inflammation, it must be tightly regulated, otherwise it may lead to serious tissue damage due the overproduction of inflammatory cytokines [33]. The secretion of cytokines is regulated at the transcriptional level, and many of them are also regulated at the posttranslational level [34]. Considering that the exposure to pathogens and chemicals is the first step in inflammation, the gastrointestinal environment has a crucial role in this process. Gut epithelial cells are the first cells to be exposed to both microbiota and food components, leading these cells to be key players influenced by food antigens, pathogens, toxins, and also by bodily metabolism and functions. Furthermore, the gut epithelial cells are the first line of defense against pathogens, complementing the action of the associated mucosal immune system, the development and maintenance of which are induced by the microbiota [35]. Some intestinal diseases are largely affected by the gut microbiota, such as inflammatory bowel disease (IBD), and Crohn's disease (CD) [36].

#### **2.2. Components of inflammasomes**

The mechanisms to identify an insult and trigger an immune response may vary according the kind of the antigenic molecule. In order to identify different antigen molecules, the innate immune cells of mammals can detect these molecules through a fixed number of germline-encoded pattern recognition receptors (PRRs), which have the ability to recognize microbial structures called pathogen-associated molecular patterns (PAMPs), such as microbial nucleic acid and bacterial cell wall [37]. Furthermore, damaged host cells can release some molecules termed danger-associated molecular patterns (DAMPs), such as ATP, reactive oxygen species (ROS) and uric acid, which also have the ability to trigger PRRs [38]. Some PRRs are located in the cell membrane and endosomes and are called toll like receptors (TLRs) and C-type lectin receptors (CLRs), which are able to recognize PAMPs and DAMPs located in the extracellular milieu. The other class of receptors is the NOD-like receptors (NLRs), which are located inside the cell in the cytoplasm [39].

TLRs were first characterized by Christiane Nusslein-Volhard in 1985, when she observed that the protein encoded by *Toll* gene was responsible for preventing the dorsoventral patterning in *Drosophila* embryos [40]. Later, it was observed that TLRs trigger a specific response for different microbes, ending up in the activation of specific regulatory pathways [41]. To date, several TLRs have been classified in mammals and theirs targets identified. Highly conserved, TLRs belong to type 1 transmembrane glycoproteins and are composed of three main structural components: a leucine-rich motif for ligand recognition at N-terminus; a single transmembrane helix; and a cytoplasmic Toll/interleukin-1 (IL-1) receptor domain at C-terminus, as reviewed by Gao and coworkers [42]. TLRs can be expressed on cell membrane, as well as on endosomal membrane. The TLRs expressed on cell membrane are TLR1, TLR2, TLR4, TLR5, TLR6, TLR10, TLR11 and TLR12, whereas TLR3, TLR7, TLR8, TLR9 and TLR13 are expressed on endosomal membrane [43]. Each TLR specifically binds to microbial molecules, triggering a cascade of signals that result in the transcription and production of pro-inflammatory cytokines and chemokines. TLR4 is one of the most studied TLRs due its ability to detect lipopolysaccharide (LPS), leading to the activation of both myeloid differentiation antigen 88 (MyD88)-dependent and MyD88-independent pathways [44]. Downstream, MyD88 is responsible for the activation of the master transcriptional regulators MAPK and NF-κB, which increase transcriptional expression of IL-1β, IL-6, IL-8 and IL-18 [45].

Like TLRs, NLRs can sense different molecules and trigger an inflammatory response. NLRs also have a structure composed of three main domains: caspase recruitment domain (CARD) or pyrin domain (PYR) at N-terminal; the highly conserved NATCH domain, a nucleotide-binding domain (also called as NBD); and leucine-rich repeats (LRR) at the C-terminal [46]. Based on the N-terminal domain, NLRs are subdivided into 8 sub-families (**Figure 2**). The LRRs are responsible for microbial molecule detection, whereas the CARD and PYD domains are responsible for homotypic and heterotypic interactions of NLRs with downstream molecules, such as procaspase, directly or via the adaptor molecule, apoptotic-associated speck like protein (ASC) [47].

#### **2.3. Inflammasome assembly**

**2. The effects of probiotics on the inflammasome**

26 Probiotics - Current Knowledge and Future Prospects

**2.1. Inflammasome: the interface between detection and response in inflammation**

biota, such as inflammatory bowel disease (IBD), and Crohn's disease (CD) [36].

The mechanisms to identify an insult and trigger an immune response may vary according the kind of the antigenic molecule. In order to identify different antigen molecules, the innate immune cells of mammals can detect these molecules through a fixed number of germline-encoded pattern recognition receptors (PRRs), which have the ability to recognize microbial structures called pathogen-associated molecular patterns (PAMPs), such as microbial nucleic acid and bacterial cell wall [37]. Furthermore, damaged host cells can release some molecules termed danger-associated molecular patterns (DAMPs), such as ATP, reactive oxygen species (ROS) and uric acid, which also have the ability to trigger PRRs [38]. Some PRRs are located in the cell membrane and endosomes and are called toll like receptors (TLRs) and C-type lectin receptors (CLRs), which are able to recognize PAMPs and DAMPs located in the extracellular milieu. The other class of receptors

is the NOD-like receptors (NLRs), which are located inside the cell in the cytoplasm [39].

TLRs were first characterized by Christiane Nusslein-Volhard in 1985, when she observed that the protein encoded by *Toll* gene was responsible for preventing the dorsoventral patterning in *Drosophila* embryos [40]. Later, it was observed that TLRs trigger a specific response for different microbes, ending up in the activation of specific regulatory pathways [41]. To date, several TLRs have been classified in mammals and theirs targets identified. Highly conserved, TLRs belong to type 1 transmembrane glycoproteins and are composed of three main structural components: a leucine-rich motif for ligand recognition at N-terminus; a single transmembrane helix; and a cytoplasmic Toll/interleukin-1 (IL-1) receptor domain at C-terminus, as reviewed by Gao and coworkers [42]. TLRs can be expressed on cell membrane, as well as on endosomal membrane. The

**2.2. Components of inflammasomes**

Inflammation is a complex immune response to many different insults, such as pathogens, cell death, and chemicals, which promotes survival during infectious diseases or injuries, as well as maintains tissue homeostasis. When an insult is identified, a cascade of signals is triggered, concluding in the recruitment of neutrophils and macrophages, which have the ability to produce several cytokines and chemokines. Despite the beneficial effects of inflammation, it must be tightly regulated, otherwise it may lead to serious tissue damage due the overproduction of inflammatory cytokines [33]. The secretion of cytokines is regulated at the transcriptional level, and many of them are also regulated at the posttranslational level [34]. Considering that the exposure to pathogens and chemicals is the first step in inflammation, the gastrointestinal environment has a crucial role in this process. Gut epithelial cells are the first cells to be exposed to both microbiota and food components, leading these cells to be key players influenced by food antigens, pathogens, toxins, and also by bodily metabolism and functions. Furthermore, the gut epithelial cells are the first line of defense against pathogens, complementing the action of the associated mucosal immune system, the development and maintenance of which are induced by the microbiota [35]. Some intestinal diseases are largely affected by the gut micro-

> Once epithelial cells recognize PAMPs or DAMPs, many different responses can be triggered in order to eliminate the source of those molecules. One well-known response against pathogens is called the inflammasome. Inflammasomes are a multiprotein complex formed in response to PAMPs and DAMPs, resulting in the activation of caspase-1 (canonical pathways) or caspase-11 (non-canonical pathway) [48]. NLRs located in the cytosol act as sensors of these microbial molecules, leading to the activation of the inflammasome complex. The inflammasome is basically composed by the NLR family members, which may contain the PYR domain or just the CARD, and by the adapter ASC. ASC has both CARD and PYD domains, and the association between ASC and CARD-containing NLRs recruits caspase-1 via homotypic interactions [49]. Despite around 23 NLR genes having been identified to date, only some of them can form oligomeric complexes which end up in the post-translational activation of caspases [50]. The hallmark of the inflammasome is the recruitment of caspase-1 in the canonical pathway, which is further released and subsequently activated via auto cleavage. Active caspase-1 can cleave and activate more than 70 substrates. This sequential process will finally release active caspase-1 to activate the IL-1β cytokine and gasdermin-D to promote adaptive and humoral immunity (**Figure 2**) [51]. In the non-canonical pathway, cleavage and activation of interleukins can also occur via caspase-4/caspase-5 (humans) or caspase-11 (rodents) [52].

> Despite the fact that caspase-1 is a protein that plays an important role in many different pathways, one of the most studied ones is pyroptosis, which is a cell death caused by inflammation in response to microbial infections or nonmicrobial stimuli [53]. In pyroptosis, caspase-1 is activated through inflammasome assembly and its active form can then cleave gasdermin-D (GSDMD) at Asp276, which generates the N-terminal cleavage product (GSDMD-NT) triggering pyroptosis and cell death. GSDMD-NT has the ability to form pores on the cell membrane, leading to cell leakage and the release of pro-inflammatory cytokines [54]. Moreover, active

dysbiosis, has been observed in several pathological conditions such as obesity, diabetes, and IBD, encompassing ulcerative colitis (UC) and CD [56, 57]. In humans, susceptibility to type 1 diabetes has been associated with changes in the gut microbiota composition, with a significant augmentation of bacteria of the Bacteroidetes phylum, and lower concentrations of *Bifidobacterium, Lactobacillus,* and *Clostridium* strains [58]. The search for probiotic strains that can reestablish host health has strongly increased in the past decades. Most of the microflora of healthy hosts is composed of bacteria from four bacterial phyla: Firmicutes, Bacteroidetes, Actinobacteria, and Proteobacteria [59]. The genus *Lactobacillus* belongs to the Firmicutes phylum, which explains the

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The inflammasome has been considered as an important regulator of intestinal homeostasis, due the central role of IL-1β and IL-18 in Th1 responses by the induction of IFNγ [60]. Moreover, IL-1β is responsible for induction of neutrophil influx, activation of myeloid cells and lymphocytes, and stimulation of Th17 differentiation [61]. Despite the fact that activation of inflammasomes increases the maturation of the pro-inflammatory cytokines IL-1β and IL-18, there is some evidence that the inflammasomes are important for keeping intestinal homeostasis and reducing morbidity and mortality in dextran sulfate sodium (DSS)-induced colitis in mice. It has been shown that mice deficient in some NLRs, such as NLRP1, NLRP3, NLRP6, NLRP12, AIM2, or deficient in ASC exhibited higher levels of pro-inflammatory mediators, as well as an increase in the epithelial damage within the colon, as reviewed by Chen [60]. Surprisingly, the severity of DSS-induced colitis seems to be reduced when antibiotic therapy is provided to mice, which strongly suggests the role of the gut microbiota in the phenotype of inflammasome-deficient mice [62]. This result was also observed in another experiment where inflammasome-deficient mice were cohoused with wild-type mice or with mothers of the opposite phenotype. After some days living together, an increase in colitis

The mechanism by which inflammasomes can affect the gut microbiota composition is still unclear. However, the effects of IL-18 on the production of antimicrobial peptides (AMPs) have revealed a possible explanation. IL-18 is able to upregulate the production of AMPs, which is crucial for microbial clearance [63]. *Asc−/−, caspase-1−/−, AIM2−/−, or Nllrp6−/−* mice have shown lower levels of AMPs when compared with WT, but normal levels of specific AMPs are restored after the administration of recombinant IL-18 [60]. Considering that AMPs can be produced to target a specific microbe, the modulation of AMP production can contribute to the abundance of certain bacterial populations. Administration of Ang4, a well characterized AMP, into *Asc−/−* mice changed the overall diversity and community of gut microbiome, but it was still significantly distinct from the WT mice [63]. All these data suggest that despite the activation of the inflammasome increasing the release of pro-inflammatory cytokines, shutting down this pathway also contributes to undesired inflammation. Thus, the modulation of the inflammasome seems to be a key factor in the prevention of exaggerated inflammation.

Many studies have focused on the use of probiotic strains that could avoid or ameliorate inflammation. One promising treatment for IBD is the commercially available probiotic mixture VLS#3,

large amount of studies with *Lactobacillus* species being administered as probiotics.

transmissibility through microbial transfer was observed.

**2.5. Probiotics and inflammasome**

**Figure 2.** NLRs families and triggering of the inflammasome. (A) NRRs currently known families, showing the highly conserved NACHT domain; (B) differences between ASC-dependent and ASC-independent binding to caspase-1; (C) schematic activation of the inflammasome.

caspase-1 can also cleave pro-interleukin-1β (pro-IL-1β) and pro-interleukin-18 (pro-IL-18) into their active form. IL-1β is a pyrogenic cytokine that can promote adaptive and humoral immunity. Neither IL-1β nor IL-18 are secreted by the endoplasmic reticulum-Golgi route. Nevertheless, IL-18 is constitutively expressed in macrophages, whereas IL-1β expression is regulated by NF-κB-mediated transcription [48]. There are other signals that can also trigger the auto-cleavage of pro-caspase-1 independent of NLRP3 activation. Some examples of these secondary signals are ROS and unfolded proteins [55].

#### **2.4. Dysbiosis and inflammasomes**

The gastrointestinal system harbors a diverse and complex microbial community that has a pivotal role in host health. However, changes in the microbiota population can have major consequences, beneficial or harmful, for host health. The disruption of the gut microbiota, called dysbiosis, has been observed in several pathological conditions such as obesity, diabetes, and IBD, encompassing ulcerative colitis (UC) and CD [56, 57]. In humans, susceptibility to type 1 diabetes has been associated with changes in the gut microbiota composition, with a significant augmentation of bacteria of the Bacteroidetes phylum, and lower concentrations of *Bifidobacterium, Lactobacillus,* and *Clostridium* strains [58]. The search for probiotic strains that can reestablish host health has strongly increased in the past decades. Most of the microflora of healthy hosts is composed of bacteria from four bacterial phyla: Firmicutes, Bacteroidetes, Actinobacteria, and Proteobacteria [59]. The genus *Lactobacillus* belongs to the Firmicutes phylum, which explains the large amount of studies with *Lactobacillus* species being administered as probiotics.

The inflammasome has been considered as an important regulator of intestinal homeostasis, due the central role of IL-1β and IL-18 in Th1 responses by the induction of IFNγ [60]. Moreover, IL-1β is responsible for induction of neutrophil influx, activation of myeloid cells and lymphocytes, and stimulation of Th17 differentiation [61]. Despite the fact that activation of inflammasomes increases the maturation of the pro-inflammatory cytokines IL-1β and IL-18, there is some evidence that the inflammasomes are important for keeping intestinal homeostasis and reducing morbidity and mortality in dextran sulfate sodium (DSS)-induced colitis in mice. It has been shown that mice deficient in some NLRs, such as NLRP1, NLRP3, NLRP6, NLRP12, AIM2, or deficient in ASC exhibited higher levels of pro-inflammatory mediators, as well as an increase in the epithelial damage within the colon, as reviewed by Chen [60]. Surprisingly, the severity of DSS-induced colitis seems to be reduced when antibiotic therapy is provided to mice, which strongly suggests the role of the gut microbiota in the phenotype of inflammasome-deficient mice [62]. This result was also observed in another experiment where inflammasome-deficient mice were cohoused with wild-type mice or with mothers of the opposite phenotype. After some days living together, an increase in colitis transmissibility through microbial transfer was observed.

The mechanism by which inflammasomes can affect the gut microbiota composition is still unclear. However, the effects of IL-18 on the production of antimicrobial peptides (AMPs) have revealed a possible explanation. IL-18 is able to upregulate the production of AMPs, which is crucial for microbial clearance [63]. *Asc−/−, caspase-1−/−, AIM2−/−, or Nllrp6−/−* mice have shown lower levels of AMPs when compared with WT, but normal levels of specific AMPs are restored after the administration of recombinant IL-18 [60]. Considering that AMPs can be produced to target a specific microbe, the modulation of AMP production can contribute to the abundance of certain bacterial populations. Administration of Ang4, a well characterized AMP, into *Asc−/−* mice changed the overall diversity and community of gut microbiome, but it was still significantly distinct from the WT mice [63]. All these data suggest that despite the activation of the inflammasome increasing the release of pro-inflammatory cytokines, shutting down this pathway also contributes to undesired inflammation. Thus, the modulation of the inflammasome seems to be a key factor in the prevention of exaggerated inflammation.

#### **2.5. Probiotics and inflammasome**

caspase-1 can also cleave pro-interleukin-1β (pro-IL-1β) and pro-interleukin-18 (pro-IL-18) into their active form. IL-1β is a pyrogenic cytokine that can promote adaptive and humoral immunity. Neither IL-1β nor IL-18 are secreted by the endoplasmic reticulum-Golgi route. Nevertheless, IL-18 is constitutively expressed in macrophages, whereas IL-1β expression is regulated by NF-κB-mediated transcription [48]. There are other signals that can also trigger the auto-cleavage of pro-caspase-1 independent of NLRP3 activation. Some examples of these

**Figure 2.** NLRs families and triggering of the inflammasome. (A) NRRs currently known families, showing the highly conserved NACHT domain; (B) differences between ASC-dependent and ASC-independent binding to caspase-1;

The gastrointestinal system harbors a diverse and complex microbial community that has a pivotal role in host health. However, changes in the microbiota population can have major consequences, beneficial or harmful, for host health. The disruption of the gut microbiota, called

secondary signals are ROS and unfolded proteins [55].

**2.4. Dysbiosis and inflammasomes**

(C) schematic activation of the inflammasome.

28 Probiotics - Current Knowledge and Future Prospects

Many studies have focused on the use of probiotic strains that could avoid or ameliorate inflammation. One promising treatment for IBD is the commercially available probiotic mixture VLS#3, which is a mixture of eight strains of lactic acid-producing bacteria (*Lactobacillus plantarum, Lactobacillus delbrueckii* subsp. *Bulgaricus, Lactobacillus casei, Lactobacillus acidophilus, Bifidobacterium breve, Bifidobacterium longum, Bifidobacterium infantis* and *Streptococcus salivarius* subsp. *Thermophilus*). VLS#3 has been shown the ability to ameliorate and prevent colitis in the Il10−/− murine model [64]. The mechanisms by which VLS#3 can reduce intestinal inflammation are still unclear, but several independent results have shown the effects of VLS#3 on the gastrointestinal tract. It was observed that the administration of VLS#3 decreases the biodiversity of the luminal microbiota on TNBSinduced chronic colitis rats [65]. Moreover, TNBS-induced colitis rats treated with VLS#3 have demonstrated pro-inflammatory cytokine and chemokine levels similar to the levels observed in normal rats [66]. These results are in agreement with the effects of VLS#3 observed on the inflammasome of NOD mice: decreasing the mRNA levels of *Il1b* and increasing the mRNA levels of *Ido*, an immunomodulatory enzyme, comparable to control group levels [67]. Surprisingly, VLS#3 treated NOD mice also reduced effective T cells/regulatory T cells (Teff/Treg) ratios at both systemic and pancreatic lymph nodes levels, helping in the maintenance of the immune homeostasis and avoiding excess inflammation.

and the administration of IL-1β have been characterized as triggers of depression-like behavior [72]. Nevertheless, higher levels of caspase-1 and NLRP3 mRNA have been observed in blood cells of depressed patients, which suggests that the inflammasome pathway may play a key role in the development of depression [73]. *Casp1−/−* mice showed decreased depressive and anxiety-like behaviors after a forced swim test compared with WT mice [74]. The effects of chronic restraint stress assay, which increases the caspase-1 and IL-1β levels, also resulted in altered gut microbiota compared to non-stressed mice. The relative abundances of the genera *Allobaculum, Bifidobacterium, Turicibacter, Clostridium,* and the family S24-7 were significantly reduced in restrained animals, whereas the abundance of the family Lachnospiraceae showed an increase. *Bifidobacterium* spp. is a genus associated with the suppression of inflammation by the inhibition of the nuclear factor-κ-B (NF-κB) pathway [75]. All these findings strongly support the notion that the inhibition of caspase-1 can reduce the stress response by modulating the interface between stress and the gut microbiota, and that the gut microbiota can exert some

A Network of Physiological Interactions Modulating GI Homeostasis: Probiotics, Inflammasome…

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In the past decade, many studies have demonstrated the effects of the gut microbiota on metabolic diseases. In comparing the gut microbiota of two distinct kinds of rats, the Biobreeding Diabetes Prone (BB-DP) and the Biobreeding Diabetes Resistant (BB-DR) rats, a higher abundance of *Lactobacillus* and *Bifidobacterium* species was identified in BB-DR stool samples [56]. One of the most prevalent species found in this work was *Lactobacillus johnsonii*, which was isolated from the stool of BB-DR rats. *L. johnsonii* has two cinnamoyl esterases that utilizes many phenolic compound as substrates [17]. One well known substrate is rosmarinic acid (RA), a phenolic compound extracted from diverse kinds of plants from the Nepetoideae subfamily of the Lamiaceae family [76]. These cinnamoyl esterases can cleave RA into its two components, caffeic acid (CA) and 3,4-dihydroxyphenylactic acid (DOPAC). Both RA and its components are well known for their antioxidant and anti-inflammatory properties [77, 78]. Based on the activity of the cinnamoyl esterases on RA, a recent study compared the effects of *L. johnsonii* N6.2 when administrated alone or in combination with RA on the inflammasome pathway in the ileum tissue of BB-DP rats fed daily with these treatments. It was observed that, despite higher levels of caspase-1 mRNA and higher levels of pro-caspase-1 in the rats fed with *L. johnsonii* N6.2, this strain decreased the concentration of the active caspase-1, compared to the animals fed with RA alone or in combination with the bacterium [79]. In the same study, it was observed that only RA significantly induced the expression of the *Il1b* gene, 12.5-fold compared to the PBS control. Consequently, RA-fed rats accumulate higher amounts of total IL-1β in the tissue. Lower levels of the pro-inflammatory cytokines TNFα and IFNγ were also observed in BB-DP rats fed with *L. johnsonii* N6.2 [80]. A similar result was observed in dogs with chronic enteropathy (CE) that were treated *ex-vivo* and *in-vivo* with *Enterococcus faecium* [81]. It was observed that *ex-vivo* stimulation of duodenal biopsies with *E. faecium* increased the mRNA levels of caspase-1 in CE dogs. However, the protein levels of IL-1β was significantly reduced after treatment. Moreover, *L. johnsonii* N6.2 demon-

important effects on brain function via the inflammasome signaling.

strated to be able to produce H2

O2

2,3-dioxygenase (IDO). IDO is the rate-limiting enzyme of tryptophan catabolism, converting tryptophan into *L-*kynurenine. The accumulation of cytotoxic kynurenines due to higher IDO activity can result in localized immunosuppression [82]. All these anti-inflammatory activities

, which has an inhibitory effect on the enzyme indoleamine

Due to the proximity of the vaginal mucosa to the gastrointestinal system, the vaginal microbiota is largely affected by the gut microbiota, being dominated by Lactobacilli [68]. Recently, *Lactobacillus rhamnosus* GR-1 has been reported to be able to limit *Escherichia coli*-induced inflammatory response in Bovine Endometrial Epithelial Cells [69]. It was observed that *L. rhamnosus* reduces inflammation by downregulating *Tlr2, Tlr4, Nod1* gene expression, as well as the downregulation of *Myd88* and *Nfkb* mRNA levels. Moreover, this strain showed the ability to reduce mRNA levels of the main components of the inflammasome: NLRP3, ASC, and Caspase-1. Consequently, the mRNA levels of the pro-inflammatory cytokines IL-1β, IL-6, IL-8, IL-18, and TNFα where suppressed by *L. rhamnosus*.

The activation of the inflammasome seems to not be dependent on bacterial viability or require phagocytosis, but the potassium efflux seems to be crucial. A study with bone marrow-derived macrophages (BMDMs) incubated with heat-killed *B. infantis* did not show an increase in the IL-1β levels when compared to cytokine levels when BMDMs were incubated with live bacteria. However, when the cells were incubated with heat-killed bacteria overnight, the IL-1β levels were similar to the levels observed when incubated with live bacteria [70]. In the same work, it was observed that using cytochalasin D, a phagocytosis inhibitor, did not significantly change the IL-1β levels. Interestingly, when WT macrophages were incubated with high concentrations of potassium or with the potassium channel blocker ruthenium red, the levels of IL-1β were significantly lower in response to *B. infantis* or *B. fragilis*, suggesting that the activation of NLRP3 inflammasome is dependent on potassium efflux.

The modulation of the inflammasome by probiotics or gut microbiota does not only affect the gastrointestinal system. In fact, the gut microbiota can modulate the inflammasomes and its effects systemically. The concentrations of pro- and anti-inflammatory cytokines have been correlated with some neurological pathologies, such as depression, which is characterized by high levels of pro-inflammatory cytokines (i.e. IL-1β and IL-6) and low levels of anti-inflammatory cytokines (i.e. IL-4 and IL-10) [71]. Moreover, more IL-1 receptor type-I and its ligands have been found to be highly expressed in brain areas related to stress response, and chronic stress and the administration of IL-1β have been characterized as triggers of depression-like behavior [72]. Nevertheless, higher levels of caspase-1 and NLRP3 mRNA have been observed in blood cells of depressed patients, which suggests that the inflammasome pathway may play a key role in the development of depression [73]. *Casp1−/−* mice showed decreased depressive and anxiety-like behaviors after a forced swim test compared with WT mice [74]. The effects of chronic restraint stress assay, which increases the caspase-1 and IL-1β levels, also resulted in altered gut microbiota compared to non-stressed mice. The relative abundances of the genera *Allobaculum, Bifidobacterium, Turicibacter, Clostridium,* and the family S24-7 were significantly reduced in restrained animals, whereas the abundance of the family Lachnospiraceae showed an increase. *Bifidobacterium* spp. is a genus associated with the suppression of inflammation by the inhibition of the nuclear factor-κ-B (NF-κB) pathway [75]. All these findings strongly support the notion that the inhibition of caspase-1 can reduce the stress response by modulating the interface between stress and the gut microbiota, and that the gut microbiota can exert some important effects on brain function via the inflammasome signaling.

which is a mixture of eight strains of lactic acid-producing bacteria (*Lactobacillus plantarum, Lactobacillus delbrueckii* subsp. *Bulgaricus, Lactobacillus casei, Lactobacillus acidophilus, Bifidobacterium breve, Bifidobacterium longum, Bifidobacterium infantis* and *Streptococcus salivarius* subsp. *Thermophilus*). VLS#3 has been shown the ability to ameliorate and prevent colitis in the Il10−/− murine model [64]. The mechanisms by which VLS#3 can reduce intestinal inflammation are still unclear, but several independent results have shown the effects of VLS#3 on the gastrointestinal tract. It was observed that the administration of VLS#3 decreases the biodiversity of the luminal microbiota on TNBSinduced chronic colitis rats [65]. Moreover, TNBS-induced colitis rats treated with VLS#3 have demonstrated pro-inflammatory cytokine and chemokine levels similar to the levels observed in normal rats [66]. These results are in agreement with the effects of VLS#3 observed on the inflammasome of NOD mice: decreasing the mRNA levels of *Il1b* and increasing the mRNA levels of *Ido*, an immunomodulatory enzyme, comparable to control group levels [67]. Surprisingly, VLS#3 treated NOD mice also reduced effective T cells/regulatory T cells (Teff/Treg) ratios at both systemic and pancreatic lymph nodes levels, helping in the maintenance of the immune homeostasis

Due to the proximity of the vaginal mucosa to the gastrointestinal system, the vaginal microbiota is largely affected by the gut microbiota, being dominated by Lactobacilli [68]. Recently, *Lactobacillus rhamnosus* GR-1 has been reported to be able to limit *Escherichia coli*-induced inflammatory response in Bovine Endometrial Epithelial Cells [69]. It was observed that *L. rhamnosus* reduces inflammation by downregulating *Tlr2, Tlr4, Nod1* gene expression, as well as the downregulation of *Myd88* and *Nfkb* mRNA levels. Moreover, this strain showed the ability to reduce mRNA levels of the main components of the inflammasome: NLRP3, ASC, and Caspase-1. Consequently, the mRNA levels of the pro-inflammatory cytokines

The activation of the inflammasome seems to not be dependent on bacterial viability or require phagocytosis, but the potassium efflux seems to be crucial. A study with bone marrow-derived macrophages (BMDMs) incubated with heat-killed *B. infantis* did not show an increase in the IL-1β levels when compared to cytokine levels when BMDMs were incubated with live bacteria. However, when the cells were incubated with heat-killed bacteria overnight, the IL-1β levels were similar to the levels observed when incubated with live bacteria [70]. In the same work, it was observed that using cytochalasin D, a phagocytosis inhibitor, did not significantly change the IL-1β levels. Interestingly, when WT macrophages were incubated with high concentrations of potassium or with the potassium channel blocker ruthenium red, the levels of IL-1β were significantly lower in response to *B. infantis* or *B. fragilis*, suggesting that the activation of NLRP3 inflammasome is dependent on potassium efflux.

The modulation of the inflammasome by probiotics or gut microbiota does not only affect the gastrointestinal system. In fact, the gut microbiota can modulate the inflammasomes and its effects systemically. The concentrations of pro- and anti-inflammatory cytokines have been correlated with some neurological pathologies, such as depression, which is characterized by high levels of pro-inflammatory cytokines (i.e. IL-1β and IL-6) and low levels of anti-inflammatory cytokines (i.e. IL-4 and IL-10) [71]. Moreover, more IL-1 receptor type-I and its ligands have been found to be highly expressed in brain areas related to stress response, and chronic stress

IL-1β, IL-6, IL-8, IL-18, and TNFα where suppressed by *L. rhamnosus*.

and avoiding excess inflammation.

30 Probiotics - Current Knowledge and Future Prospects

In the past decade, many studies have demonstrated the effects of the gut microbiota on metabolic diseases. In comparing the gut microbiota of two distinct kinds of rats, the Biobreeding Diabetes Prone (BB-DP) and the Biobreeding Diabetes Resistant (BB-DR) rats, a higher abundance of *Lactobacillus* and *Bifidobacterium* species was identified in BB-DR stool samples [56]. One of the most prevalent species found in this work was *Lactobacillus johnsonii*, which was isolated from the stool of BB-DR rats. *L. johnsonii* has two cinnamoyl esterases that utilizes many phenolic compound as substrates [17]. One well known substrate is rosmarinic acid (RA), a phenolic compound extracted from diverse kinds of plants from the Nepetoideae subfamily of the Lamiaceae family [76]. These cinnamoyl esterases can cleave RA into its two components, caffeic acid (CA) and 3,4-dihydroxyphenylactic acid (DOPAC). Both RA and its components are well known for their antioxidant and anti-inflammatory properties [77, 78]. Based on the activity of the cinnamoyl esterases on RA, a recent study compared the effects of *L. johnsonii* N6.2 when administrated alone or in combination with RA on the inflammasome pathway in the ileum tissue of BB-DP rats fed daily with these treatments. It was observed that, despite higher levels of caspase-1 mRNA and higher levels of pro-caspase-1 in the rats fed with *L. johnsonii* N6.2, this strain decreased the concentration of the active caspase-1, compared to the animals fed with RA alone or in combination with the bacterium [79]. In the same study, it was observed that only RA significantly induced the expression of the *Il1b* gene, 12.5-fold compared to the PBS control. Consequently, RA-fed rats accumulate higher amounts of total IL-1β in the tissue. Lower levels of the pro-inflammatory cytokines TNFα and IFNγ were also observed in BB-DP rats fed with *L. johnsonii* N6.2 [80]. A similar result was observed in dogs with chronic enteropathy (CE) that were treated *ex-vivo* and *in-vivo* with *Enterococcus faecium* [81]. It was observed that *ex-vivo* stimulation of duodenal biopsies with *E. faecium* increased the mRNA levels of caspase-1 in CE dogs. However, the protein levels of IL-1β was significantly reduced after treatment. Moreover, *L. johnsonii* N6.2 demonstrated to be able to produce H2 O2 , which has an inhibitory effect on the enzyme indoleamine 2,3-dioxygenase (IDO). IDO is the rate-limiting enzyme of tryptophan catabolism, converting tryptophan into *L-*kynurenine. The accumulation of cytotoxic kynurenines due to higher IDO activity can result in localized immunosuppression [82]. All these anti-inflammatory activities of *L. johnsonii* N6.2 along with its ability to modulate the host immune responses may explain the mitigation of type 1 diabetes in BB-DP rats when fed daily with this bacterium [15, 83].

mTORC1 [89]. Autophagy is inhibited by mTORC1 through the inhibition two main effectors: ULK1 and DAP1 [90]. ULK1 is a kinase that forms a complex with other proteins required for

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Even though mTORC2 still holds many secrets, we do know a bit about the complex and the functions it regulates. Along with mTOR itself, this second mTOR complex also contains mLST8 and DEPTOR. However, instead of Raptor, mTORC2 contains Rictor (rapamycininsensitive companion of mTOR), mSIN (mammalian stress-activated map kinase interacting protein 1) and protor 1/2 (protein observed with Rictor 1 and 2) [85]. While mTORC1 is known to be affected by many external stimuli, mTORC2 is resistant to nutrients but is affected by growth factors through a mechanism requiring PI3K. Though this mechanism is poorly understood, it may require the use of ribosomes as ribosomes are needed for mTORC2

Not much is known about mTORC2 activation and downstream studies do not hold many answers either. It does seem to primarily control cell survival and proliferation. It is known that when mTORC2 is activated it phosphorylates and fully activates AKT by phosphorylating at serine473 [92]. This mTORC2-dependent phosphorylation unlocks the AKT functions of inhibiting transcription factors FoxO1/3a, which regulates energy metabolism and apoptosis [93]. However, this phosphorylation is not required for AKT inhibition of the TSC complex, therefore mTORC1-dependent functions are not affected. mTORC2 can also directly phosphorylate SGK1, a kinase that controls ion transport and also inhibits FoxO1/3a [94]. Lastly, mTORC2 also regulates cytoskeletal dynamics through the activation of paxillin, PKC-

Since the mTOR pathway is heavily involved in functions affecting survival and growth and responds to growth factors, energy status, amino acids and oxygen, it is not at all surprising that deregulation of this pathway can cause serious systemic problems. Indeed, mTOR is a very complex pathway that seems to play a central role in many fundamental cellular processes. Since new mechanisms of action and regulation are constantly being discovered, it seems that this pathway still has many secrets to be told. Due to the importance of the functions mTOR controls, it is extremely important to keep this pathway in-check. Certainly, this pathway does contain intricate negative feedback loops and inactivating enzymes to prevent the pathway from going into a chronic state of activation. However, like all well-organized systems, a simple flaw could wreak havoc on the system, and there have been plenty of cases reported in disease and research of the consequences that occur in these circumstances.

Since the mTOR pathway integrates glucose homeostasis and lipid synthesis, it is not difficult to believe that disruptions in this pathway can lead to serious metabolic diseases. Indeed, mTOR has been heavily involved in obesity-related comorbidities, such as type 2 diabetes. A high fat diet, a contributing factor to these diseases, has been known to raise insulin, amino acids, and pro-inflammatory cytokines levels, which can affect mTOR activity. Type 2 diabetes occurs when cells become immune to insulin, even when sufficient insulin levels

α, and Rho GTPases, ultimately affecting cell shape and migration [95].

autophagosome formation while DAP1 directly negatively regulates autophagy.

activation via a PI3K-dependent process [91].

**3.3. mTOR deregulation in disease**

#### **3. Probiotic effects on a master regulatory pathway**

#### **3.1. mTOR: a master regulator of major cellular functions**

Like any living thing, a cell's main goal is to grow, proliferate, and ultimately, survive. This requires the coordination of multiple environmental signals, working synergistically through several pathways in order to culminate into a common outcome. Intricate organization and intracellular crosstalk is necessary for this to be accomplished. Often, these coordinated signals require a regulator to ensure that these functions are carried out efficiently. For most of these processes, the mechanistic target of rapamycin (mTOR) could be considered that important moderator. mTOR is a serine/threonine kinase that presents itself into two distinct complexes: mTORC1 and mTORC2. Ultimately, this pathway integrates external and internal cues to encourage a cell to grow, proliferate, and survive. It senses a diverse set of nutritional and environmental stimuli, including growth factors, amino acids, energy levels, oxygen and stress in order to stimulate anabolic cellular processes like protein and lipid synthesis, and to discourage catabolic processes like autophagy. Deregulation of this pathway has been heavily linked to metabolic disorders and cancer [84].

#### **3.2. The mTOR complexes: mTORC1 and mTORC2**

As of today, mTORC1 is better characterized out of the two mTOR complexes. This complex is composed of three core proteins and two inhibitory proteins as follows: mTOR, Raptor (regulatory protein associated with mTOR), mLST8 (mammalian lethal with Sec13 protein 8), DEPTOR (DEP domain containing mTOR interacting protein), and PRAS40 (proline-rich AKT substrate of 40kDA) [85]. A popular path to mTORC1 activation is through PI3K/AKT [86]. Here, growth factors and hormones bind to their receptor and activate the intracellular phosphatidylinositide 3-kinase (PI3K) which, through multiple interactions, leads to phosphorylation and partial activation of protein kinase B (AKT). AKT activation phosphorylates and consequently inhibits the tuberous sclerosis complex (TSC). This inactivation stimulates mTOR by inactivating Rheb's (Ras homolog enriched in brain) GTPase domain so that active GTP-bound Rheb binds to mTOR.

Activation of mTORC1 leads to an increase in protein synthesis, lipid biosynthesis, and a decrease in autophagy [85]. Downstream, mTORC1 promotes protein synthesis essentially through two main effectors: p70S6 kinase 1 (S6K1) and eIF4E binding protein (4EBP). S6K1 can also influence lipid biosynthesis by activating the sterol responsive element binding protein (SREBP), which promotes the transcription of genes involved in fatty acid and cholesterol biosynthesis [87]. However, this transcription factor can also be activated by mTORC1, by inhibiting Lipin1, a protein the keeps SREBP localized to the cytoplasm [88]. Peroxisome proliferator-activated receptor (PPAR), a main regulator of adipogenesis, is also activated by mTORC1 [89]. Autophagy is inhibited by mTORC1 through the inhibition two main effectors: ULK1 and DAP1 [90]. ULK1 is a kinase that forms a complex with other proteins required for autophagosome formation while DAP1 directly negatively regulates autophagy.

Even though mTORC2 still holds many secrets, we do know a bit about the complex and the functions it regulates. Along with mTOR itself, this second mTOR complex also contains mLST8 and DEPTOR. However, instead of Raptor, mTORC2 contains Rictor (rapamycininsensitive companion of mTOR), mSIN (mammalian stress-activated map kinase interacting protein 1) and protor 1/2 (protein observed with Rictor 1 and 2) [85]. While mTORC1 is known to be affected by many external stimuli, mTORC2 is resistant to nutrients but is affected by growth factors through a mechanism requiring PI3K. Though this mechanism is poorly understood, it may require the use of ribosomes as ribosomes are needed for mTORC2 activation via a PI3K-dependent process [91].

Not much is known about mTORC2 activation and downstream studies do not hold many answers either. It does seem to primarily control cell survival and proliferation. It is known that when mTORC2 is activated it phosphorylates and fully activates AKT by phosphorylating at serine473 [92]. This mTORC2-dependent phosphorylation unlocks the AKT functions of inhibiting transcription factors FoxO1/3a, which regulates energy metabolism and apoptosis [93]. However, this phosphorylation is not required for AKT inhibition of the TSC complex, therefore mTORC1-dependent functions are not affected. mTORC2 can also directly phosphorylate SGK1, a kinase that controls ion transport and also inhibits FoxO1/3a [94]. Lastly, mTORC2 also regulates cytoskeletal dynamics through the activation of paxillin, PKCα, and Rho GTPases, ultimately affecting cell shape and migration [95].

#### **3.3. mTOR deregulation in disease**

of *L. johnsonii* N6.2 along with its ability to modulate the host immune responses may explain the mitigation of type 1 diabetes in BB-DP rats when fed daily with this bacterium [15, 83].

Like any living thing, a cell's main goal is to grow, proliferate, and ultimately, survive. This requires the coordination of multiple environmental signals, working synergistically through several pathways in order to culminate into a common outcome. Intricate organization and intracellular crosstalk is necessary for this to be accomplished. Often, these coordinated signals require a regulator to ensure that these functions are carried out efficiently. For most of these processes, the mechanistic target of rapamycin (mTOR) could be considered that important moderator. mTOR is a serine/threonine kinase that presents itself into two distinct complexes: mTORC1 and mTORC2. Ultimately, this pathway integrates external and internal cues to encourage a cell to grow, proliferate, and survive. It senses a diverse set of nutritional and environmental stimuli, including growth factors, amino acids, energy levels, oxygen and stress in order to stimulate anabolic cellular processes like protein and lipid synthesis, and to discourage catabolic processes like autophagy. Deregulation of this pathway has been heavily

As of today, mTORC1 is better characterized out of the two mTOR complexes. This complex is composed of three core proteins and two inhibitory proteins as follows: mTOR, Raptor (regulatory protein associated with mTOR), mLST8 (mammalian lethal with Sec13 protein 8), DEPTOR (DEP domain containing mTOR interacting protein), and PRAS40 (proline-rich AKT substrate of 40kDA) [85]. A popular path to mTORC1 activation is through PI3K/AKT [86]. Here, growth factors and hormones bind to their receptor and activate the intracellular phosphatidylinositide 3-kinase (PI3K) which, through multiple interactions, leads to phosphorylation and partial activation of protein kinase B (AKT). AKT activation phosphorylates and consequently inhibits the tuberous sclerosis complex (TSC). This inactivation stimulates mTOR by inactivating Rheb's (Ras homolog enriched in brain) GTPase domain so that active

Activation of mTORC1 leads to an increase in protein synthesis, lipid biosynthesis, and a decrease in autophagy [85]. Downstream, mTORC1 promotes protein synthesis essentially through two main effectors: p70S6 kinase 1 (S6K1) and eIF4E binding protein (4EBP). S6K1 can also influence lipid biosynthesis by activating the sterol responsive element binding protein (SREBP), which promotes the transcription of genes involved in fatty acid and cholesterol biosynthesis [87]. However, this transcription factor can also be activated by mTORC1, by inhibiting Lipin1, a protein the keeps SREBP localized to the cytoplasm [88]. Peroxisome proliferator-activated receptor (PPAR), a main regulator of adipogenesis, is also activated by

**3. Probiotic effects on a master regulatory pathway**

**3.1. mTOR: a master regulator of major cellular functions**

32 Probiotics - Current Knowledge and Future Prospects

linked to metabolic disorders and cancer [84].

GTP-bound Rheb binds to mTOR.

**3.2. The mTOR complexes: mTORC1 and mTORC2**

Since the mTOR pathway is heavily involved in functions affecting survival and growth and responds to growth factors, energy status, amino acids and oxygen, it is not at all surprising that deregulation of this pathway can cause serious systemic problems. Indeed, mTOR is a very complex pathway that seems to play a central role in many fundamental cellular processes. Since new mechanisms of action and regulation are constantly being discovered, it seems that this pathway still has many secrets to be told. Due to the importance of the functions mTOR controls, it is extremely important to keep this pathway in-check. Certainly, this pathway does contain intricate negative feedback loops and inactivating enzymes to prevent the pathway from going into a chronic state of activation. However, like all well-organized systems, a simple flaw could wreak havoc on the system, and there have been plenty of cases reported in disease and research of the consequences that occur in these circumstances.

Since the mTOR pathway integrates glucose homeostasis and lipid synthesis, it is not difficult to believe that disruptions in this pathway can lead to serious metabolic diseases. Indeed, mTOR has been heavily involved in obesity-related comorbidities, such as type 2 diabetes. A high fat diet, a contributing factor to these diseases, has been known to raise insulin, amino acids, and pro-inflammatory cytokines levels, which can affect mTOR activity. Type 2 diabetes occurs when cells become immune to insulin, even when sufficient insulin levels accumulate to signal cells to take up glucose. mTORC1 has been implicated in regulating the insulin-producing pancreatic β cell function, as β cell-specific TSC component knockout mice revealed that young mice experienced increased β cell mass coordinated with higher insulin levels and increased glucose tolerance [96]. However, as the mice aged, these observations reversed, resulting in a decline of β-cell function over time [97]. This biphasic display could be explained through the feedback inhibition of insulin/PI3K/AKT by constitutive S6K1 expression [98]. At first, constant mTORC1 expression improves β-cell function, however this constant activation eventually accumulates in the S6K1-mediated inhibition of IRS1 upstream of mTORC1. Decrease in β cell function is also observed when mTORC2 signaling is knocked out. In this case, activation of AKT does not occur, which encourages FoxO1 activation. This causes a defect in glucose metabolism, leading to glucose intolerance due to a reduction in β-cell mass and proliferation, affecting insulin production and secretion [99]. It is clear that mTOR is a major regulator in β-cell viability and insulin signaling. Deregulation of this pathway has a great potential to cause insulin resistance leading to diabetes onset.

4,5-bisphosphate (PIP2) to phosphatidylinositol 3,4,5-trisphosphate (PIP3). PTEN recycles PIP3 back to PIP2, blocking downstream PI3K/AKT/mTOR signaling. Mutations in this gene blocks the ability of PTEN to recycle PIP3 and deactivate downstream effects, and it has been found to be frequently mutated in human cancers [107]. Another tumor suppressor, TSC1/2, suppresses chronic mTOR activation but, when mutated, can lead to abnormal and unregulated growth [108]. Hyperactivation of mTOR can also happen at the genomic level, as mutations in *MTOR* have also been found in various cancers [109]. Other oncogenic genes, such as *Akt*, *Pi3k*, and *Rheb*, have been described to encourage proliferation and tumor progression. Many of the pathways genes and proteins have been credited with encouraging a proliferative state when manipulated, and since the mTOR pathway is so vast and largely unknown, pinpointing the problem becomes an impossible feat. Even more challenging is finding treatments that are effective and do not have

A Network of Physiological Interactions Modulating GI Homeostasis: Probiotics, Inflammasome…

http://dx.doi.org/10.5772/intechopen.72656

35

In response to stimulatory signals, such as insulin and nutrients, the combination of increased adiposity and insulin resistance resulting from chronic mTOR activation is the main driving factors contributing to metabolic disease. To further complicate the scene, genetic mutations or aberrantly functioning proteins can force a cell into a constitutively growing and dividing unit, reminiscent of cancer. Cancer and metabolic disorders are some of the most common diseases in modern times. To contain or prevent the occurrences of these diseases are the topics of many current research and clinical trials. The mTOR pathway coordinates cell growth and environmental conditions through an intercalated network that must adapt to unstable conditions. The complexity of this pathway, the diverse signals it recognizes, and the importance of the functions it regulates makes this a promising, albeit cumbersome, target for therapeutic intervention.

Although no studies have directly explored the interaction of probiotics with the mTOR pathway, it is likely to surface soon. With the microbiome a popular topic in research in relation to disease onset and now the emergence of mTOR as a main regulator of essential cellular functions whose deregulation is indicated in disease, it would be not all too surprising if a connection could be made between the two. To be able to implement a non-invasive strategy to treat diseases such as cancer or type 2 diabetes would be a huge leap forward in medical technology. Indeed, a main goal in microbiome research is to be able to understand the effects of these microorganisms in the gastrointestinal context, and to dissect their interactions with the host and their environment, including other microbial species and luminal contents. Though many groups have reported on some of the effects of specific microbial species, there is still much left to be discovered. Here, we will consider some of the connections these effects may have with the mTOR pathway (**Figure 3**), and discuss the potential consequences this may have on the host. In many cases, disease onset is preceded by a systemic inflammatory response. This is also the case in cancer and metabolic disorders. As mentioned, inflammatory cytokines, such as TNFα, are known to be potent inducers of mTOR activity. TNFα is known to inhibit TSC1 through its activation of IKKβ, a link that has also been exposed in tumor angiogenesis [110]. A significant elevation of pro-inflammatory cytokines has also been described to be associated with metabolic disorders, such as obesity and type 2 diabetes. As is the case with cancer,

**3.4. Therapeutic probiotic strategies to modulating mTOR**

downstream adverse effects.

mTOR signaling also plays a significant role in obesity and non-alcoholic fatty liver disease, both of which can be characterized by an increase in adipogenesis. Fat, the most important energy storage site, accumulates in an mTORC1-activated state, while loss of mTORC1 results in leanness and resistance to high fat diet-induced obesity through enhanced mitochondrial respiration [100, 101]. This is because downstream effectors of mTORC1, 4E-BP and S6K1, regulate adipogenic transcription factors and their translation [102, 103]. Loss of mTORC2, on the other hand, results in impaired glucose transport in response to insulin stimulation and increased lipolysis translating to an escalation in circulating free fatty acids and glycerol [104]. Proliferation of adipose tissue is recognized to be the highest risk factor in developing obesity-related diseases. Over-activation of mTOR has been heavily connected in the tissues of obese and high fat diet-fed animals and its regulation is critical in maintaining a healthy state.

The liver is a multifaceted organ. Not only does it filter and detoxify the blood, it also produces and stores compounds utilized by the whole body. Of importance to this discussion, the liver is responsible for producing triglycerides, cholesterol, and ketone bodies that peripheral organs use as an energy source in low nutrient states. Like adipose tissue and pancreas, mTORC1/S6K1 activity in the liver is high in obese or nutrient dense states, leading to feedback inhibition of IRS and insulin resistance. This inhibition leads to the hyperglycemia and hyperinsulinemia characteristic of type 2 diabetes and insulin resistance. Interestingly, in the liver as well as other tissues, insulin loses its sensitivity yet still retains its ability to stimulate fatty acid synthesis. This could be explained by the fact that FoxO1 in primarily responsible for glucose metabolism in an mTORC2-dependent process, while mTORC1 promotes lipogenesis and this is primarily controlled via SREBP expression [105, 106]. Therefore, this may promote the double-edged sword of glucose intolerance and the stimulation of lipogenic processes, leading to obesity and insulin resistance in an mTOR-dependent manner.

Lastly, imperfect mTOR signaling plays an important role in many cancers. This pathway is made up of many proto-oncogenes and tumor suppressors that, if affected, could turn a cell into a constitutively growing and proliferating state characteristic of cancers. PTEN (phosphatase and tensin homolog) antagonizes the actions of PI3K, which phosphorylates phosphatidylinositol 4,5-bisphosphate (PIP2) to phosphatidylinositol 3,4,5-trisphosphate (PIP3). PTEN recycles PIP3 back to PIP2, blocking downstream PI3K/AKT/mTOR signaling. Mutations in this gene blocks the ability of PTEN to recycle PIP3 and deactivate downstream effects, and it has been found to be frequently mutated in human cancers [107]. Another tumor suppressor, TSC1/2, suppresses chronic mTOR activation but, when mutated, can lead to abnormal and unregulated growth [108]. Hyperactivation of mTOR can also happen at the genomic level, as mutations in *MTOR* have also been found in various cancers [109]. Other oncogenic genes, such as *Akt*, *Pi3k*, and *Rheb*, have been described to encourage proliferation and tumor progression. Many of the pathways genes and proteins have been credited with encouraging a proliferative state when manipulated, and since the mTOR pathway is so vast and largely unknown, pinpointing the problem becomes an impossible feat. Even more challenging is finding treatments that are effective and do not have downstream adverse effects.

In response to stimulatory signals, such as insulin and nutrients, the combination of increased adiposity and insulin resistance resulting from chronic mTOR activation is the main driving factors contributing to metabolic disease. To further complicate the scene, genetic mutations or aberrantly functioning proteins can force a cell into a constitutively growing and dividing unit, reminiscent of cancer. Cancer and metabolic disorders are some of the most common diseases in modern times. To contain or prevent the occurrences of these diseases are the topics of many current research and clinical trials. The mTOR pathway coordinates cell growth and environmental conditions through an intercalated network that must adapt to unstable conditions. The complexity of this pathway, the diverse signals it recognizes, and the importance of the functions it regulates makes this a promising, albeit cumbersome, target for therapeutic intervention.

#### **3.4. Therapeutic probiotic strategies to modulating mTOR**

accumulate to signal cells to take up glucose. mTORC1 has been implicated in regulating the insulin-producing pancreatic β cell function, as β cell-specific TSC component knockout mice revealed that young mice experienced increased β cell mass coordinated with higher insulin levels and increased glucose tolerance [96]. However, as the mice aged, these observations reversed, resulting in a decline of β-cell function over time [97]. This biphasic display could be explained through the feedback inhibition of insulin/PI3K/AKT by constitutive S6K1 expression [98]. At first, constant mTORC1 expression improves β-cell function, however this constant activation eventually accumulates in the S6K1-mediated inhibition of IRS1 upstream of mTORC1. Decrease in β cell function is also observed when mTORC2 signaling is knocked out. In this case, activation of AKT does not occur, which encourages FoxO1 activation. This causes a defect in glucose metabolism, leading to glucose intolerance due to a reduction in β-cell mass and proliferation, affecting insulin production and secretion [99]. It is clear that mTOR is a major regulator in β-cell viability and insulin signaling. Deregulation of this path-

34 Probiotics - Current Knowledge and Future Prospects

way has a great potential to cause insulin resistance leading to diabetes onset.

mTOR signaling also plays a significant role in obesity and non-alcoholic fatty liver disease, both of which can be characterized by an increase in adipogenesis. Fat, the most important energy storage site, accumulates in an mTORC1-activated state, while loss of mTORC1 results in leanness and resistance to high fat diet-induced obesity through enhanced mitochondrial respiration [100, 101]. This is because downstream effectors of mTORC1, 4E-BP and S6K1, regulate adipogenic transcription factors and their translation [102, 103]. Loss of mTORC2, on the other hand, results in impaired glucose transport in response to insulin stimulation and increased lipolysis translating to an escalation in circulating free fatty acids and glycerol [104]. Proliferation of adipose tissue is recognized to be the highest risk factor in developing obesity-related diseases. Over-activation of mTOR has been heavily connected in the tissues of obese and high fat diet-fed animals and its regulation is critical in maintaining a healthy state.

The liver is a multifaceted organ. Not only does it filter and detoxify the blood, it also produces and stores compounds utilized by the whole body. Of importance to this discussion, the liver is responsible for producing triglycerides, cholesterol, and ketone bodies that peripheral organs use as an energy source in low nutrient states. Like adipose tissue and pancreas, mTORC1/S6K1 activity in the liver is high in obese or nutrient dense states, leading to feedback inhibition of IRS and insulin resistance. This inhibition leads to the hyperglycemia and hyperinsulinemia characteristic of type 2 diabetes and insulin resistance. Interestingly, in the liver as well as other tissues, insulin loses its sensitivity yet still retains its ability to stimulate fatty acid synthesis. This could be explained by the fact that FoxO1 in primarily responsible for glucose metabolism in an mTORC2-dependent process, while mTORC1 promotes lipogenesis and this is primarily controlled via SREBP expression [105, 106]. Therefore, this may promote the double-edged sword of glucose intolerance and the stimulation of lipogenic pro-

cesses, leading to obesity and insulin resistance in an mTOR-dependent manner.

Lastly, imperfect mTOR signaling plays an important role in many cancers. This pathway is made up of many proto-oncogenes and tumor suppressors that, if affected, could turn a cell into a constitutively growing and proliferating state characteristic of cancers. PTEN (phosphatase and tensin homolog) antagonizes the actions of PI3K, which phosphorylates phosphatidylinositol Although no studies have directly explored the interaction of probiotics with the mTOR pathway, it is likely to surface soon. With the microbiome a popular topic in research in relation to disease onset and now the emergence of mTOR as a main regulator of essential cellular functions whose deregulation is indicated in disease, it would be not all too surprising if a connection could be made between the two. To be able to implement a non-invasive strategy to treat diseases such as cancer or type 2 diabetes would be a huge leap forward in medical technology. Indeed, a main goal in microbiome research is to be able to understand the effects of these microorganisms in the gastrointestinal context, and to dissect their interactions with the host and their environment, including other microbial species and luminal contents. Though many groups have reported on some of the effects of specific microbial species, there is still much left to be discovered. Here, we will consider some of the connections these effects may have with the mTOR pathway (**Figure 3**), and discuss the potential consequences this may have on the host.

In many cases, disease onset is preceded by a systemic inflammatory response. This is also the case in cancer and metabolic disorders. As mentioned, inflammatory cytokines, such as TNFα, are known to be potent inducers of mTOR activity. TNFα is known to inhibit TSC1 through its activation of IKKβ, a link that has also been exposed in tumor angiogenesis [110]. A significant elevation of pro-inflammatory cytokines has also been described to be associated with metabolic disorders, such as obesity and type 2 diabetes. As is the case with cancer,

diabetes is dramatically increasing and it continues to be one of the most prevalent diseases threatening human health, there have been many studies commenting on probiotic intervention to reduce symptoms of type 2 diabetes. Several *Bifidobacterium* and *Lactobacillus* strains are described to reducing weight gain, improving insulin-glucose homeostasis and overall improving metabolic syndrome in obese or high fat diet-fed mice [113, 114]. Even a study on a probiotic yeast was found to reduce metabolic syndrome symptoms and hepatic steatosis in obese and diabetic animals [115]. Clinical studies are now investigating this relationship and have reported improved insulin resistance in high fat, over-fed circumstances [116, 117]. However, these studies have rarely looked directly at the mechanism in which these probiotics contribute to human health, and even less often have any investigated into the effects on mTOR. Needless to say, it is possible that these mechanisms could be mTOR-mediated, how-

A Network of Physiological Interactions Modulating GI Homeostasis: Probiotics, Inflammasome…

http://dx.doi.org/10.5772/intechopen.72656

37

One of the many benefits that our microbial symbionts provide for us is the ability to produce or release substances that our bodies are not capable of doing itself. These substances include vitamins, antimicrobials, butyrate, and other short chain fatty acids (SCFA). In fact, even the famous inhibitor in which the pathway is named after, rapamycin, is produced by the bacterium *Streptomyces hygroscopicus*, providing more evidence that microbes can make specific ligands that interfere with the activity of mTOR enzymes. Studies have elucidated the beneficial effects of butyrate have on colon diseases, such as ulcerative colitis, Crohn's disease, and cancer [118]. To date, two main SCFA signaling mechanisms have been described: the inactivation of histone deacetylases (HDAC) and the stimulation of G-protein-coupled receptors. One study has even uncovered the role of HDAC-activated S6K1 in promoting immune tolerance through T-cell differentiation into effector and regular T cells due to SCFAs [119]. This response is important when cells are faced with a potent stimulus. Instead of over reacting to the stimuli, the T cells emit tolerant signals to be able to neutralize the threat instead of creating a systemic inflammatory response. Additionally, some probiotic strains encode for unique enzymes that can cleave off phenols, or natural antioxidants, from dietary fiber [17, 120, 121]. Coincidentally, many of the inhibitors of the mTOR pathway, such as the popular rapamycin and its derivatives, are cyclic and phenolic in nature. This opens up a new avenue of research, exploring natural food components released by probiotics in controlling pathways whose deregulation is associated with diseases. Few studies have explored this area, but one group discusses the ability of cranberry proanthocyanins to encourage autophagy in esophageal adenocarcinoma cells via inhibition of the PI3K/AKT/mTOR pathway [122]. Another phenolic compound isolated from a shrub is described to disrupt mTORC1 complex and activate the AMPK/TSC signaling cascade, preventing breast tumor growth [123]. Since mTOR activity is aggressive in tumor development, preventing its bodily dissemination through natural food components seems like a far less intrusive procedure than current cancer therapies. Lastly, bacteria can alter the bioavailability of amino acids through their natural metabolism. They can utilize host-derived amino acids, provide amino acids to the host, or disrupt host pathways involved in amino acid digestion or synthesis [80, 124]. Amino acids, particularly arginine and leucine, are essential for mTORC1 activation [125]. Commensals in the intestine have been reported in utilizing these amino acids for protein synthesis, thereby limiting their availability for host-sensitive pathways [126, 127]. However, amino acid producing bacteria within the human intestine can contribute to this available pool of amino acids [128]. The homeostatic maintenance of the bioavailable

ever more work into this area is needed.

**Figure 3.** A simple representation of the mTOR pathway and some potential probiotic targets. External signals such as inflammation, growth factors, insulin, and amino acids can stimulate mTOR activity through a cascade of upstream effectors. These can activate processes that are required for a cell to grow, proliferate and survive. Using probiotics to target some of these stimulatory signals or enzymes within the pathway can help modulate its effects regarding disease onset.

IKKβ seems to also link inflammation to obesity-induced insulin resistance, and its inhibition could potentially be used to treat insulin resistance [111]. Coincidentally, numerous studies on probiotic strains have focused on alleviating inflammation and have even reported this to be correlated with reduced disease onset [15, 112]. Reducing the circulation of inflammatory cytokines will be less effective in activating IKKβ and therefore stimulating mTOR activity. Therefore, the successful alleviation of inflammatory cytokines with probiotics has the potential to reduce the activation of mTOR and its downstream effects, potentially reducing the incidence of modern diseases associated with chronic mTOR activation.

Insulin resistance occurs when the hormone insulin is insufficient in triggering cells to take in glucose to be converted into energy. Although insulin is produced at reasonable levels, glucose cannot enter the cells and therefore builds up in the blood, leading to hyperglycemia. Both insulin resistance and hyperglycemia are characteristic of type 2 diabetes, and it has been explained that chronic mTOR activation can contribute to this through the negative feedback loop connecting S6K1 to IRS. Obesity and a poor diet have also been described to be risk factors for type 2 diabetes, and associated with mTOR activity. Since the occurrence of type 2 diabetes is dramatically increasing and it continues to be one of the most prevalent diseases threatening human health, there have been many studies commenting on probiotic intervention to reduce symptoms of type 2 diabetes. Several *Bifidobacterium* and *Lactobacillus* strains are described to reducing weight gain, improving insulin-glucose homeostasis and overall improving metabolic syndrome in obese or high fat diet-fed mice [113, 114]. Even a study on a probiotic yeast was found to reduce metabolic syndrome symptoms and hepatic steatosis in obese and diabetic animals [115]. Clinical studies are now investigating this relationship and have reported improved insulin resistance in high fat, over-fed circumstances [116, 117]. However, these studies have rarely looked directly at the mechanism in which these probiotics contribute to human health, and even less often have any investigated into the effects on mTOR. Needless to say, it is possible that these mechanisms could be mTOR-mediated, however more work into this area is needed.

One of the many benefits that our microbial symbionts provide for us is the ability to produce or release substances that our bodies are not capable of doing itself. These substances include vitamins, antimicrobials, butyrate, and other short chain fatty acids (SCFA). In fact, even the famous inhibitor in which the pathway is named after, rapamycin, is produced by the bacterium *Streptomyces hygroscopicus*, providing more evidence that microbes can make specific ligands that interfere with the activity of mTOR enzymes. Studies have elucidated the beneficial effects of butyrate have on colon diseases, such as ulcerative colitis, Crohn's disease, and cancer [118]. To date, two main SCFA signaling mechanisms have been described: the inactivation of histone deacetylases (HDAC) and the stimulation of G-protein-coupled receptors. One study has even uncovered the role of HDAC-activated S6K1 in promoting immune tolerance through T-cell differentiation into effector and regular T cells due to SCFAs [119]. This response is important when cells are faced with a potent stimulus. Instead of over reacting to the stimuli, the T cells emit tolerant signals to be able to neutralize the threat instead of creating a systemic inflammatory response. Additionally, some probiotic strains encode for unique enzymes that can cleave off phenols, or natural antioxidants, from dietary fiber [17, 120, 121]. Coincidentally, many of the inhibitors of the mTOR pathway, such as the popular rapamycin and its derivatives, are cyclic and phenolic in nature. This opens up a new avenue of research, exploring natural food components released by probiotics in controlling pathways whose deregulation is associated with diseases. Few studies have explored this area, but one group discusses the ability of cranberry proanthocyanins to encourage autophagy in esophageal adenocarcinoma cells via inhibition of the PI3K/AKT/mTOR pathway [122]. Another phenolic compound isolated from a shrub is described to disrupt mTORC1 complex and activate the AMPK/TSC signaling cascade, preventing breast tumor growth [123]. Since mTOR activity is aggressive in tumor development, preventing its bodily dissemination through natural food components seems like a far less intrusive procedure than current cancer therapies. Lastly, bacteria can alter the bioavailability of amino acids through their natural metabolism. They can utilize host-derived amino acids, provide amino acids to the host, or disrupt host pathways involved in amino acid digestion or synthesis [80, 124]. Amino acids, particularly arginine and leucine, are essential for mTORC1 activation [125]. Commensals in the intestine have been reported in utilizing these amino acids for protein synthesis, thereby limiting their availability for host-sensitive pathways [126, 127]. However, amino acid producing bacteria within the human intestine can contribute to this available pool of amino acids [128]. The homeostatic maintenance of the bioavailable

IKKβ seems to also link inflammation to obesity-induced insulin resistance, and its inhibition could potentially be used to treat insulin resistance [111]. Coincidentally, numerous studies on probiotic strains have focused on alleviating inflammation and have even reported this to be correlated with reduced disease onset [15, 112]. Reducing the circulation of inflammatory cytokines will be less effective in activating IKKβ and therefore stimulating mTOR activity. Therefore, the successful alleviation of inflammatory cytokines with probiotics has the potential to reduce the activation of mTOR and its downstream effects, potentially reducing the

**Figure 3.** A simple representation of the mTOR pathway and some potential probiotic targets. External signals such as inflammation, growth factors, insulin, and amino acids can stimulate mTOR activity through a cascade of upstream effectors. These can activate processes that are required for a cell to grow, proliferate and survive. Using probiotics to target some of these stimulatory signals or enzymes within the pathway can help modulate its effects regarding disease

Insulin resistance occurs when the hormone insulin is insufficient in triggering cells to take in glucose to be converted into energy. Although insulin is produced at reasonable levels, glucose cannot enter the cells and therefore builds up in the blood, leading to hyperglycemia. Both insulin resistance and hyperglycemia are characteristic of type 2 diabetes, and it has been explained that chronic mTOR activation can contribute to this through the negative feedback loop connecting S6K1 to IRS. Obesity and a poor diet have also been described to be risk factors for type 2 diabetes, and associated with mTOR activity. Since the occurrence of type 2

incidence of modern diseases associated with chronic mTOR activation.

onset.

36 Probiotics - Current Knowledge and Future Prospects

pool of amino acids by the gut microbiota may be an important modulator of mTOR activity *in vivo*, thereby controlling disease development. Still, with the emergence of new mTOR data, we are finding that the list of potential inducers of mTOR to be very extensive. Although arginine and leucine are deemed the most important inducers of mTOR, other amino acids have been found to be able to trigger this pathway, and bacteria that have the ability to disrupt host biochemical pathways can regulate this expression [80, 129]. The complexity of the microbialhost relationship in the context of communal metabolites provides an intricate insight into the regulation of important regulatory pathways.

**References**

[1] World Health Organization and Food and Agricultural Organization of the United Nations. Probiotics in food: Health and nutritional properties and guidelines for evalu-

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http://dx.doi.org/10.5772/intechopen.72656

39

[2] Parker EA, Roy T, D'Adamo CR, Wieland LS. Probiotics and gastrointestinal conditions: An overview of evidence from the Cochrane Collaboration. Nutrition. 2017 Jul;**47**:125-134

[3] Gasbarrini G, Bonvicini F, Gramenzi A. Probiotics history. Journal of Clinical Gastroen-

[4] Cordina C, Shaikh I, Shrestha S, Camilleri-Brennan J. Probiotics in the management of gastrointestinal disease: Analysis of the attitudes and prescribing practices of gastroen-

[5] Butel M. Probiotics, gut microbiota and health. Médecine et Maladies Infectieuses.

[6] Markowiak P, Śliżewska K. Effects of probiotics, prebiotics, and synbiotics on human

[7] Gedek BR. Adherence of *Escherichia coli* serogroup O 157 and the *Salmonella typhimurium* mutant DT 104 to the surface of *Saccharomyces boulardii*. Mycoses. 1999;**42**(4):261-264 [8] Schachtsiek M, Hammes WP, Hertel C. Characterization of *Lactobacillus coryniformis* DSM 20001T surface protein Cpf mediating coaggregation with and aggregation among pathogens. Applied and Environmental Microbiology. 2004 Dec;**70**(12):7078-7085 [9] Parvez S, Malik KA, Ah Kang S, Kim H-Y. Probiotics and their fermented food products are beneficial for health. Journal of Applied Microbiology. 2006 Jun;**100**(6):1171-1185 [10] La Fata G, Weber P, Mohajeri MH. Probiotics and the gut immune system: Indirect regulation. Probiotics and Antimicrobial Proteins. Advance online publication. DOI:10.1007/

[11] Kanatani K, Oshimura M, Sano K. Isolation and characterization of acidocin A and cloning of the bacteriocin gene from *Lactobacillus acidophilus*. Applied and Environmental Microbiology [Internet]. 1995 Mar;**61**(3):1061-1067. Available from: http://www.ncbi.

[12] Todorov SD, Rachman C, Fourrier A, Dicks LMT, van Reenen CA, Prévost H, et al. Characterization of a bacteriocin produced by *Lactobacillus sakei* R1333 isolated from smoked salmon. Anaerobe [Internet]. 2011 Feb;**17**(1):23-31. Available from: http://www.

[13] Schoster A, Kokotovic B, Permin A, Pedersen PD, Bello FD, Guardabassi L. In vitro inhibition of *Clostridium difficile* and *Clostridium perfringens* by commercial probiotic strains.

[14] Cash HL. Symbiotic bacteria direct expression of an intestinal bactericidal lectin. Science

terologists and surgeons. Journal of Digestive Diseases. 2011 Dec;**12**(6):489-496

ation. FAO Food and Nutrition Paper. 2006;**85**:2

terology. 2016;**50**:S116-S119

health. Nutrients. 2017 Sep;**9**(9):1021

2014;**44**(1):1-8

s12602-017-9322-6

nlm.nih.gov/pubmed/7793908

Anaerobe. 2013 Apr;**20**:36-41

ncbi.nlm.nih.gov/pubmed/20152920

(80-). 2006 Aug;**313**(5790):1126-1130

The reduction of mTOR through pharmaceutical intervention has also been a popular area for research. One drawback to this method is that these techniques aim to directly inhibit this pathway through contact with its key mediators. Although, this seems like the simplest and most effective way to prevent mTOR-mediated disease onset, it could create drastic effects. Since this pathway focuses on essential cellular functions, total inhibition of this pathway could do more harm than good. As these drugs are sometimes not natural chemicals, they can also induce unrelated but potentially critical side effects in the body. The best method of action may be to focus on indirect approaches to modulate mTOR activity, rather than trying to completely prevent its activation. These indirect methods could come in the form of moderating its stimulatory signals, such as inflammation and insulin. As we discover more of the health benefits probiotics have to offer, it is clear that this is a multifaceted interaction with the host. After all, these are living organisms, consuming, excreting, and doing what is necessary to survive rather than a chemical that has no consideration of its existence. It is possible that this complex relationship could be what we need to keep our body in balance. Therefore, the answers to relieving some of today's most aggressive diseases could come from our own microflora.

#### **Acknowledgements**

This work was funded by the National Institute of Food and Agriculture USDA Grant No. 2015-67017-23182.

#### **Conflict of interest**

Authors declare no conflicts of interest.

#### **Author details**

Danielle N. Kling, Leandro D. Teixeira, Evon M. DeBose-Scarlett and Claudio F. Gonzalez\*

\*Address all correspondence to: cfgonzalez@ufl.edu

Department of Microbiology and Cell Science, Genetics Institute, Institute of Food and Agricultural Sciences (IFAS), University of Florida, Gainesville, Florida, USA

#### **References**

pool of amino acids by the gut microbiota may be an important modulator of mTOR activity *in vivo*, thereby controlling disease development. Still, with the emergence of new mTOR data, we are finding that the list of potential inducers of mTOR to be very extensive. Although arginine and leucine are deemed the most important inducers of mTOR, other amino acids have been found to be able to trigger this pathway, and bacteria that have the ability to disrupt host biochemical pathways can regulate this expression [80, 129]. The complexity of the microbialhost relationship in the context of communal metabolites provides an intricate insight into the

The reduction of mTOR through pharmaceutical intervention has also been a popular area for research. One drawback to this method is that these techniques aim to directly inhibit this pathway through contact with its key mediators. Although, this seems like the simplest and most effective way to prevent mTOR-mediated disease onset, it could create drastic effects. Since this pathway focuses on essential cellular functions, total inhibition of this pathway could do more harm than good. As these drugs are sometimes not natural chemicals, they can also induce unrelated but potentially critical side effects in the body. The best method of action may be to focus on indirect approaches to modulate mTOR activity, rather than trying to completely prevent its activation. These indirect methods could come in the form of moderating its stimulatory signals, such as inflammation and insulin. As we discover more of the health benefits probiotics have to offer, it is clear that this is a multifaceted interaction with the host. After all, these are living organisms, consuming, excreting, and doing what is necessary to survive rather than a chemical that has no consideration of its existence. It is possible that this complex relationship could be what we need to keep our body in balance. Therefore, the answers to relieving some of today's most aggressive diseases could come from our own microflora.

This work was funded by the National Institute of Food and Agriculture USDA Grant No.

Danielle N. Kling, Leandro D. Teixeira, Evon M. DeBose-Scarlett and Claudio F. Gonzalez\*

Department of Microbiology and Cell Science, Genetics Institute, Institute of Food and

Agricultural Sciences (IFAS), University of Florida, Gainesville, Florida, USA

regulation of important regulatory pathways.

38 Probiotics - Current Knowledge and Future Prospects

**Acknowledgements**

2015-67017-23182.

**Author details**

**Conflict of interest**

Authors declare no conflicts of interest.

\*Address all correspondence to: cfgonzalez@ufl.edu


[15] Valladares R, Sankar D, Li N, Williams E, Lai K-K, Abdelgeliel AS, et al. *Lactobacillus johnsonii* N6.2 mitigates the development of type 1 diabetes in BB-DP rats. PLoS One [Internet]. 2010;**5**(5):e10507. Available from: /pmc/articles/PMC2865539/?report=abstract

[26] Ankolekar C, Johnson K, Pinto M, Johnson D, Labbe RG, Greene D, et al. Fermentation of whole apple juice using *Lactobacillus acidophilus* for potential dietary management of hyperglycemia, hypertension, and modulation of beneficial bacterial responses. Journal of Food Biochemistry [Internet]. 2012 Dec;**36**(6):718-738. Available from: http://doi.wiley.

A Network of Physiological Interactions Modulating GI Homeostasis: Probiotics, Inflammasome…

http://dx.doi.org/10.5772/intechopen.72656

41

[27] Rahimi R, Nikfar S, Rahimi F, Elahi B, Derakhshani S, Vafaie M, et al. A meta-analysis on the efficacy of probiotics for maintenance of remission and prevention of clinical and endoscopic relapse in Crohn's disease. Digestive Diseases and Sciences. 2008

[28] Hod K, Sperber AD, Ron Y, Boaz M, Dickman R, Berliner S, et al. A double-blind, placebo-controlled study to assess the effect of a probiotic mixture on symptoms and inflammatory markers in women with diarrhea-predominant IBS. Neurogastroenterology

[29] Huurre A, Laitinen K, Rautava S, Korkeamäki M, Isolauri E. Impact of maternal atopy and probiotic supplementation during pregnancy on infant sensitization: A double-blind placebo-controlled study. Clinical and Experimental Allergy. 2008 Aug;**38**(8):1342-1348

[30] Kobayashi R, Kobayashi T, Sakai F, Hosoya T, Yamamoto M, Kurita-Ochiai T. Oral administration of *Lactobacillus gasseri* SBT2055 is effective in preventing *Porphyromonas* 

[31] Xue L, He J, Gao N, Lu X, Li M, Wu X, et al. Probiotics may delay the progression of nonalcoholic fatty liver disease by restoring the gut microbiota structure and improving

[32] Fang D, Shi D, Lv L, Gu S, Wu W, Chen Y, et al. *Bifidobacterium pseudocatenulatum* LI09 and *Bifidobacterium catenulatum* LI10 attenuate D-galactosamine-induced liver injury by

[33] Chen GY, Nuñez G. Sterile inflammation: Sensing and reacting to damage. Nature Reviews. Immunology [Internet]. 2010 Dec;**10**(12):826-837. Available from: http://www.

[34] Medzhitov R. Origin and physiological roles of inflammation. Nature [Internet]. 2008 Jul 24;**454**(7203):428-435. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18650913 [35] Lallès J-P. Microbiota-host interplay at the gut epithelial level, health and nutrition. Journal of Animal Science and Biotechnology [Internet]. 2016;**7**:66. Available from: http://

[36] Lin L, Zhang J. Role of intestinal microbiota and metabolites on gut homeostasis and human diseases. BMC Immunology [Internet]. 2017 Jan 6;**18**(1):2. Available from: http://

[37] Medzhitov R, Janeway CA. Innate immune recognition and control of adaptive immune responses. Seminars in Immunology [Internet]. 1998 Oct;**10**(5):351-353. Available from:

*gingivalis*-accelerated periodontal disease. Scientific Reports. 2017 Dec;**7**(1):545

intestinal endotoxemia. Scientific Reports. 2017 Mar;**7**:45176

modifying the gut microbiota. Scientific Reports. 2017 Dec;**7**(1):8770

com/10.1111/j.1745-4514.2011.00596.x

and Motility. 2017 Jul;**29**(7):e13037

ncbi.nlm.nih.gov/pubmed/21088683

www.ncbi.nlm.nih.gov/pubmed/27833747

www.ncbi.nlm.nih.gov/pubmed/28061847

http://www.ncbi.nlm.nih.gov/pubmed/9799709

Sep;**53**(9):2524-2531


[26] Ankolekar C, Johnson K, Pinto M, Johnson D, Labbe RG, Greene D, et al. Fermentation of whole apple juice using *Lactobacillus acidophilus* for potential dietary management of hyperglycemia, hypertension, and modulation of beneficial bacterial responses. Journal of Food Biochemistry [Internet]. 2012 Dec;**36**(6):718-738. Available from: http://doi.wiley. com/10.1111/j.1745-4514.2011.00596.x

[15] Valladares R, Sankar D, Li N, Williams E, Lai K-K, Abdelgeliel AS, et al. *Lactobacillus johnsonii* N6.2 mitigates the development of type 1 diabetes in BB-DP rats. PLoS One [Internet]. 2010;**5**(5):e10507. Available from: /pmc/articles/PMC2865539/?report=abstract

[16] Kingma SDK, Li N, Sun F, Valladares RB, Neu J, Lorca GL. *Lactobacillus johnsonii* N6. 2 stimulates the innate immune response through Toll-like receptor 9 in Caco-2 cells and increases intestinal crypt Paneth cell number in biobreeding diabetes-prone rats. J Nutr

[17] Kin KL, Lorca GL, Gonzalez CF. Biochemical properties of two cinnamoyl esterases purified from a *Lactobacillus johnsonii* strain isolated from stool samples of diabetes-resistant

duction rate in *Lactobacillus johnsonii* is modulated via the interplay of a heterodimeric flavin oxidoreductase with a soluble 28 Kd PAS domain containing protein. Frontiers in Microbiology [Internet]. 2015;**6**(July):1-14. Available from: http://journal.frontiersin.org/

[19] Hole AS, Rud I, Grimmer S, Sigl S, Narvhus J, Sahlstrøm S. Improved bioavailability of dietary phenolic acids in whole grain barley and oat groat following fermentation with probiotic *Lactobacillus acidophilus*, *Lactobacillus johnsonii*, and *Lactobacillus reuteri*. Journal of Agricultural and Food Chemistry [Internet]. 2012 Jun 27;**60**(25):6369-6375. Available

[20] Motevaseli E, Dianatpour A, Ghafouri-Fard S. The role of probiotics in cancer treatment: Emphasis on their in vivo and in vitro anti-metastatic effects. International Journal of

[21] Khoury N, El-Hayek S, Tarras O, El-Sabban M, El-Sibai M, Rizk S. Kefir exhibits antiproliferative and pro-apoptotic effects on colon adenocarcinoma cells with no significant effects on cell migration and invasion. International Journal of Oncology. 2014

[22] Kuhbacher T. Bacterial and fungal microbiota in relation to probiotic therapy (VSL#3) in

[23] Zhang Y-J, Li S, Gan R-Y, Zhou T, Xu D-P, Li H-B.Impacts of gut bacteria on human health and diseases. International Journal of Molecular Sciences. 2015 Apr;**16**(4):7493-7519

[24] Gionchetti P, Rizzello F, Venturi A, Brigidi P, Matteuzzi D, Bazzocchi G, et al. Oral bacteriotherapy as maintenance treatment in patients with chronic pouchitis: A double-blind,

[25] Celiberto LS, Bedani R, Dejani NN, Ivo de Medeiros A, Sampaio Zuanon JA, Spolidorio LC, et al. Effect of a probiotic beverage consumption (*Enterococcus faecium* CRL 183 and *Bifidobacterium longum* ATCC 15707) in rats with chemically induced colitis. Smidt H,

placebo-controlled trial. Gastroenterology. 2000 Aug;**119**(2):305-309

O2 pro-

rats. Applied and Environmental Microbiology. 2009;**75**(15):5018-5024

[18] Valladares RB, Graves C, Wright K, Gardner CL, Lorca GL, Gonzalez CF. H2

[Internet]. 2011;**141**(6):1023-1028

40 Probiotics - Current Knowledge and Future Prospects

Article/10.3389/fmicb.2015.00716/abstract

from: http://www.ncbi.nlm.nih.gov/pubmed/22676388

Molecular and Cellular Medicine. 2017;**6**(2):66-76

pouchitis. Gut. 2006 Jun;**55**(6):833-841

editor. PLoS One. 2017 Apr;**12**(4):e0175935

Nov;**45**(5):2117-2127


[38] Takeuchi O, Akira S. Pattern recognition receptors and inflammation. Cell [Internet]. 2010 Mar 19;**140**(6):805-820. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20303872

[49] Lawlor KE, Vince JE. Ambiguities in NLRP3 inflammasome regulation: Is there a role for mitochondria? Biochimica et Biophysica Acta [Internet]. 2014 Apr;**1840**(4):1433-1440.

A Network of Physiological Interactions Modulating GI Homeostasis: Probiotics, Inflammasome…

http://dx.doi.org/10.5772/intechopen.72656

43

[50] Bauernfeind F, Ablasser A, Bartok E, Kim S, Schmid-Burgk J, Cavlar T, et al. Inflammasomes: Current understanding and open questions. Cellular and Molecular Life Sciences [Internet]. 2011 Mar;**68**(5):765-783. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21072676

[51] Guo H, Callaway JB, Ting JP-Y. Inflammasomes: Mechanism of action, role in disease, and therapeutics. Nature Medicine [Internet]. 2015 Jul;**21**(7):677-687. Available from:

[52] Viganò E, Diamond CE, Spreafico R, Balachander A, Sobota RM, Mortellaro A. Human caspase-4 and caspase-5 regulate the one-step non-canonical inflammasome activation in monocytes. Nature Communications [Internet]. 2015 Oct 28;**6**:8761. Available from:

[53] Miao EA, Leaf IA, Treuting PM, Mao DP, Dors M, Sarkar A, et al. Caspase-1-induced pyroptosis is an innate immune effector mechanism against intracellular bacteria. Nature Immunology [Internet]. 2010 Dec;**11**(12):1136-1142. Available from: http://www.

[54] Liu X, Zhang Z, Ruan J, Pan Y, Magupalli VG, Wu H, et al. Inflammasome-activated gasdermin D causes pyroptosis by forming membrane pores. Nature [Internet]. 2016;**535**(7610):153-158. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27383986

[55] Gurung P, Lukens JR, Kanneganti T-D. Mitochondria: Diversity in the regulation of the NLRP3 inflammasome. Trends in Molecular Medicine [Internet]. 2015 Mar;**21**(3):193-

[56] Roesch LFW, Lorca GL, Casella G, Giongo A, Naranjo A, Pionzio AM, et al. Cultureindependent identification of gut bacteria correlated with the onset of diabetes in a rat

[57] Statovci D, Aguilera M, MacSharry J, Melgar S. The impact of western diet and nutrients on the microbiota and immune response at mucosal interfaces. Frontiers in Immunology [Internet]. 2017;**8**:838. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28804483

[58] Murri M, Leiva I, Gomez-Zumaquero JM, Tinahones FJ, Cardona F, Soriguer F, et al. Gut microbiota in children with type 1 diabetes differs from that in healthy children: A casecontrol study. BMC Medicine [Internet]. 2013 Feb 21;**11**:46. Available from: http://www.

[59] Khanna S, Tosh PK. A clinician's primer on the role of the microbiome in human health and disease. Mayo Clinic Proceedings [Internet]. 2014 Jan;**89**(1):107-114. Available from:

[60] Chen GY. Regulation of the gut microbiome by inflammasomes. Free Radical Biology & Medicine [Internet]. 2017 Apr;**105**:35-40. Available from: http://www.ncbi.nlm.nih.gov/

201. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25500014

Available from: http://www.ncbi.nlm.nih.gov/pubmed/23994495

http://www.ncbi.nlm.nih.gov/pubmed/26121197

http://www.ncbi.nlm.nih.gov/pubmed/26508369

ncbi.nlm.nih.gov/pubmed/21057511

model. ISME J [Internet]. 2010;**3**(5):536-548

ncbi.nlm.nih.gov/pubmed/23433344

pubmed/27845186

http://www.ncbi.nlm.nih.gov/pubmed/24388028


[49] Lawlor KE, Vince JE. Ambiguities in NLRP3 inflammasome regulation: Is there a role for mitochondria? Biochimica et Biophysica Acta [Internet]. 2014 Apr;**1840**(4):1433-1440. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23994495

[38] Takeuchi O, Akira S. Pattern recognition receptors and inflammation. Cell [Internet]. 2010 Mar 19;**140**(6):805-820. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20303872

[39] Leifer CA, Medvedev AE. Molecular mechanisms of regulation of Toll-like receptor signaling. Journal of Leukocyte Biology [Internet]. 2016 Nov;**100**(5):927-941. Available

[40] Anderson KV, Jürgens G, Nüsslein-Volhard C. Establishment of dorsal-ventral polarity in the Drosophila embryo: Genetic studies on the role of the Toll gene product. Cell [Internet]. 1985 Oct;**42**(3):779-789. Available from: http://www.ncbi.nlm.nih.gov/pubmed/

[41] Lemaitre B, Reichhart JM, Hoffmann JA. Drosophila host defense: Differential induction of antimicrobial peptide genes after infection by various classes of microorganisms. Proceedings of the National Academy of Sciences of the United States of America [Internet]. 1997 Dec 23;**94**(26):14614-14619. Available from: http://www.ncbi.nlm.nih.

[42] Gao W, Xiong Y, Li Q, Yang H. Inhibition of Toll-like receptor signaling as a promising therapy for inflammatory diseases: A journey from molecular to nano therapeutics. Frontiers in Physiology [Internet]. 2017;**8**:508. Available from: http://www.ncbi.nlm.nih.

[43] Chauhan P, Shukla D, Chattopadhyay D, Saha B. Redundant and regulatory roles for Toll-like receptors in Leishmania infection. Clinical and Experimental Immunology [Internet]. 2017 Jul;**190**(2):167-186. Available from: http://www.ncbi.nlm.nih.gov/pubmed/

[44] Turner ML, Cronin JG, Healey GD, Sheldon IM. Epithelial and stromal cells of bovine endometrium have roles in innate immunity and initiate inflammatory responses to bacterial lipopeptides in vitro via Toll-like receptors TLR2, TLR1, and TLR6. Endocrinology [Internet]. 2014 Apr;**155**(4):1453-1465. Available from: http://www.ncbi.nlm.nih.gov/

[45] Cronin JG, Turner ML, Goetze L, Bryant CE, Sheldon IM. Toll-like receptor 4 and MYD88-dependent signaling mechanisms of the innate immune system are essential for the response to lipopolysaccharide by epithelial and stromal cells of the bovine endometrium. Biology of Reproduction [Internet]. 2012 Feb;**86**(2):51. Available from: http://

[46] Saxena S, Jha S. Role of NOD-like Receptors in Glioma Angiogenesis: Insights into future therapeutic interventions. Cytokine & Growth Factor Reviews [Internet]. 2017 Apr;**34**:

[47] Sharma N, Jha S. NLR-regulated pathways in cancer: Opportunities and obstacles for therapeutic interventions. Cellular and Molecular Life Sciences [Internet]. 2016 May; **73**(9):1741-1764. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26708292 [48] Lamkanfi M, Dixit VM. Mechanisms and functions of inflammasomes. Cell [Internet]. 2014 May 22;**157**(5):1013-1022. Available from: http://www.ncbi.nlm.nih.gov/pubmed/

15-26. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28233643

from: http://www.ncbi.nlm.nih.gov/pubmed/27343013

3931918

28708252

24855941

pubmed/24437488

www.ncbi.nlm.nih.gov/pubmed/22053092

gov/pubmed/9405661

42 Probiotics - Current Knowledge and Future Prospects

gov/pubmed/28769820


[61] Joosten LAB, Netea MG, Dinarello CA. Interleukin-1β in innate inflammation, autophagy and immunity. Seminars in Immunology [Internet]. 2013 Dec 15;**25**(6):416-424. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24275601

PLoS One [Internet]. 2016;**11**(8):e0160937. Available from: http://www.ncbi.nlm.nih.

A Network of Physiological Interactions Modulating GI Homeostasis: Probiotics, Inflammasome…

http://dx.doi.org/10.5772/intechopen.72656

45

[71] Wong M-L, Dong C, Maestre-Mesa J, Licinio J. Polymorphisms in inflammation-related genes are associated with susceptibility to major depression and antidepressant response. Molecular Psychiatry [Internet]. 2008 Aug;**13**(8):800-812. Available from: http://www.

[72] Udina M, Moreno-España J, Capuron L, Navinés R, Farré M, Vieta E, et al. Cytokineinduced depression: Current status and novel targets for depression therapy. CNS & Neurological Disorders Drug Targets [Internet]. 2014;**13**(6):1066-1074. Available from:

[73] Alcocer-Gómez E, de Miguel M, Casas-Barquero N, Núñez-Vasco J, Sánchez-Alcazar JA, Fernández-Rodríguez A, et al. NLRP3 inflammasome is activated in mononuclear blood cells from patients with major depressive disorder. Brain, Behavior, and Immunity [Internet]. 2014 Feb;**36**:111-117. Available from: http://www.ncbi.nlm.nih.gov/

[74] Wong M-L, Inserra A, Lewis MD, Mastronardi CA, Leong L, Choo J, et al. Inflammasome signaling affects anxiety- and depressive-like behavior and gut microbiome composition. Molecular Psychiatry [Internet]. 2016 Jun;**21**(6):797-805. Available from: http://

[75] Riedel C-U, Foata F, Philippe D, Adolfsson O, Eikmanns B-J, Blum S. Anti-inflammatory effects of bifidobacteria by inhibition of LPS-induced NF-kappaB activation. World Journal of Gastroenterology [Internet]. 2006 Jun 21;**12**(23):3729-3735. Available from:

[76] Amoah SKS, Sandjo LP, Kratz JM, Biavatti MW. Rosmarinic acid—Pharmaceutical and clinical aspects. Planta Medica [Internet]. 2016 Mar;**82**(5):388-406. Available from: http://

[77] Chu X, Ci X, He J, Jiang L, Wei M, Cao Q, et al. Effects of a natural prolyl oligopeptidase inhibitor, rosmarinic acid, on lipopolysaccharide-induced acute lung injury in mice. Molecules [Internet]. 2012 Mar 22;**17**(3):3586-3598. Available from: http://www.ncbi.nlm.

[78] Kovacheva E, Georgiev M, Pashova S, Angelova M, Ilieva M. Radical quenching by rosmarinic acid from *Lavandula vera* MM cell culture. Zeitschrift für Naturforschung. Section C [Internet]. 2006;**61**(7-8):517-520. Available from: http://www.ncbi.nlm.nih.gov/

[79] Teixeira L, Kling D, Lorca G, Gonzalez C. (in press). *Lactobacillus johnsonii* N6.2 diminishes Caspase-1 maturation in the gastrointestinal system of diabetes prone rats.

[80] Valladares R, Bojilova L, Potts AH, Cameron E, Gardner C, Lorca G, et al. *Lactobacillus johnsonii* inhibits indoleamine 2,3-dioxygenase and alters tryptophan metabolite levels

gov/pubmed/27505062

pubmed/24513871

ncbi.nlm.nih.gov/pubmed/18504423

http://www.ncbi.nlm.nih.gov/pubmed/24923336

www.ncbi.nlm.nih.gov/pubmed/27090302

www.ncbi.nlm.nih.gov/pubmed/26845712

nih.gov/pubmed/22441336

pubmed/16989310

Beneficial Microbes

http://www.ncbi.nlm.nih.gov/pubmed/16773690


PLoS One [Internet]. 2016;**11**(8):e0160937. Available from: http://www.ncbi.nlm.nih. gov/pubmed/27505062

[71] Wong M-L, Dong C, Maestre-Mesa J, Licinio J. Polymorphisms in inflammation-related genes are associated with susceptibility to major depression and antidepressant response. Molecular Psychiatry [Internet]. 2008 Aug;**13**(8):800-812. Available from: http://www. ncbi.nlm.nih.gov/pubmed/18504423

[61] Joosten LAB, Netea MG, Dinarello CA. Interleukin-1β in innate inflammation, autophagy and immunity. Seminars in Immunology [Internet]. 2013 Dec 15;**25**(6):416-424.

[62] Elinav E, Strowig T, Kau AL, Henao-Mejia J, Thaiss CA, Booth CJ, et al. NLRP6 inflammasome regulates colonic microbial ecology and risk for colitis. Cell [Internet]. 2011 May 27;**145**(5):745-757. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21565393

[63] Levy M, Thaiss CA, Zeevi D, Dohnalová L, Zilberman-Schapira G, Mahdi JA, et al. Microbiota-modulated metabolites shape the intestinal microenvironment by regulating NLRP6 inflammasome signaling. Cell [Internet]. 2015 Dec 3;**163**(6):1428-1443. Available

[64] Madsen KL, Doyle JS, Jewell LD, Tavernini MM, Fedorak RN. *Lactobacillus* species prevents colitis in interleukin 10 gene-deficient mice. Gastroenterology [Internet]. 1999 May;**116**(5):1107-1114. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10220502

[65] Uronis JM, Arthur JC, Keku T, Fodor A, Carroll IM, Cruz ML, et al. Gut microbial diversity is reduced by the probiotic VSL#3 and correlates with decreased TNBS-induced colitis. Inflammatory Bowel Diseases [Internet]. 2011 Jan;**17**(1):289-297. Available from:

[66] Isidro RA, Lopez A, Cruz ML, Gonzalez Torres MI, Chompre G, Isidro AA, et al. The probiotic VSL#3 modulates colonic macrophages, inflammation, and microflora in acute trinitrobenzene sulfonic acid colitis. The Journal of Histochemistry and Cytochemistry [Internet]. 2017;**65**(8):445-461. Available from: http://www.ncbi.nlm.nih.gov/pubmed/

[67] Dolpady J, Sorini C, Di Pietro C, Cosorich I, Ferrarese R, Saita D, et al. Oral probiotic VSL#3 prevents autoimmune diabetes by modulating microbiota and promoting indoleamine 2,3-dioxygenase-enriched tolerogenic intestinal environment. Journal of Diabetes Research [Internet]. 2016;**2016**:7569431. Available from: http://www.ncbi.nlm.nih.gov/

[68] McLean NW, Rosenstein IJ. Characterisation and selection of a *Lactobacillus* species to re-colonise the vagina of women with recurrent bacterial vaginosis. Journal of Medical Microbiology [Internet]. 2000 Jun;**49**(6):543-552. Available from: http://www.ncbi.nlm.

[69] Liu M, Wu Q, Wang M, Fu Y, Wang J. *Lactobacillus rhamnosus* GR-1 limits *Escherichia coli*-induced inflammatory responses via attenuating MyD88-dependent and MyD88 independent pathway activation in bovine endometrial epithelial cells. Inflammation [Internet]. 2016 Aug;**39**(4):1483-1494. Available from: http://www.ncbi.nlm.nih.gov/

[70] Chen K, Shanmugam NKN, Pazos MA, Hurley BP, Cherayil BJ. Commensal bacteria-induced inflammasome activation in mouse and human macrophages is dependent on potassium efflux but does not require phagocytosis or bacterial viability.

Available from: http://www.ncbi.nlm.nih.gov/pubmed/24275601

44 Probiotics - Current Knowledge and Future Prospects

from: http://www.ncbi.nlm.nih.gov/pubmed/26638072

http://www.ncbi.nlm.nih.gov/pubmed/20564535

28692320

pubmed/26779542

pubmed/27236308

nih.gov/pubmed/10847208


in BioBreeding rats. The FASEB Journal [Internet]. 2013;**27**(4):1711-1720. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23303207

[92] Sarbassov DD, Guertin DA, Ali SM, Sabatini DM. Phosphorylation and regulation of Akt/PKB by the rictor-mTOR complex. Science [Internet]. 2005 Feb 18;**307**(5712):1098-

A Network of Physiological Interactions Modulating GI Homeostasis: Probiotics, Inflammasome…

http://dx.doi.org/10.5772/intechopen.72656

47

[93] Guertin DA, Stevens DM, Thoreen CC, Burds AA, Kalaany NY, Moffat J, et al. Ablation in mice of the mTORC components raptor, rictor, or mLST8 reveals that mTORC2 is required for signaling to Akt-FOXO and PKCα, but not S6K1. Developmental Cell [Internet]. 2006 Dec;**11**(6):859-871. Available from: http://linkinghub.elsevier.

[94] García-Martínez JM, Alessi DR. mTOR complex 2 (mTORC2) controls hydrophobic motif phosphorylation and activation of serum- and glucocorticoid-induced protein kinase 1 (SGK1). Biochemical Journal [Internet]. 2008 Dec 15;**416**(3):375-385. Available

[95] Jacinto E, Loewith R, Schmidt A, Lin S, Rüegg MA, Hall A, et al. Mammalian TOR complex 2 controls the actin cytoskeleton and is rapamycin insensitive. Nature Cell Biology [Internet]. 2004 Nov;**6**(11):1122-1128. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15467718

[96] Mori H, Inoki K, Opland D, Munzberg H, Villanueva EC, Faouzi M, et al. Critical roles for the TSC-mTOR pathway in -cell function. AJP Endocrinology and Metabolism [Internet]. 2009 Nov 1;**297**(5):E1013-E1022. Available from: http://ajpendo.physiology.

[97] Shigeyama Y, Kobayashi T, Kido Y, Hashimoto N, Asahara S-I, Matsuda T, et al. Biphasic response of pancreatic beta-cell mass to ablation of tuberous sclerosis complex 2 in mice. Molecular and Cellular Biology [Internet]. 2008 May;**28**(9):2971-2979.

[98] Um SH, Frigerio F, Watanabe M, Picard F, Joaquin M, Sticker M, et al. Absence of S6K1 protects against age- and diet-induced obesity while enhancing insulin sensitivity. Nature [Internet]. 2004 Sep 9;**431**(7005):200-205. Available from: http://www.nature.

[99] Gu Y, Lindner J, Kumar A, Yuan W, Magnuson MA.Rictor/mTORC2 is essential for maintaining a balance between beta-cell proliferation and cell size. Diabetes [Internet]. 2011 Mar;**60**(3):827-837. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21266327 [100] Zhang HH, Huang J, Düvel K, Boback B, Wu S, Squillace RM, et al. Insulin stimulates adipogenesis through the Akt-TSC2-mTORC1 pathway. PLoS One [Internet]. 2009 Jul

10;**4**(7):e6189. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19593385 [101] Polak P, Cybulski N, Feige JN, Auwerx J, Rüegg MA, Hall MN. Adipose-specific knockout of raptor results in lean mice with enhanced mitochondrial respiration. Cell Metabolism [Internet]. 2008 Nov;**8**(5):399-410. Available from: http://www.ncbi.nlm.

[102] Carnevalli LS, Masuda K, Frigerio F, Le Bacquer O, Um SH, Gandin V, et al. S6K1 plays a critical role in early adipocyte differentiation. Developmental Cell [Internet]. 2010 May 18;**18**(5):763-774. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20493810

Available from: http://www.ncbi.nlm.nih.gov/pubmed/18316403

1101. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15718470

from: http://biochemj.org/lookup/doi/10.1042/BJ20081668

com/retrieve/pii/S153458070600459X

org/cgi/doi/10.1152/ajpendo.00262.2009

com/doifinder/10.1038/nature02866

nih.gov/pubmed/19046571


[92] Sarbassov DD, Guertin DA, Ali SM, Sabatini DM. Phosphorylation and regulation of Akt/PKB by the rictor-mTOR complex. Science [Internet]. 2005 Feb 18;**307**(5712):1098- 1101. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15718470

in BioBreeding rats. The FASEB Journal [Internet]. 2013;**27**(4):1711-1720. Available from:

[81] Schmitz S, Werling D, Allenspach K. Effects of ex-vivo and in-vivo treatment with probiotics on the inflammasome in dogs with chronic enteropathy. Sutterwala FS, editor. PLoS One [Internet]. 2015 Mar 23;**10**(3):e0120779. Available from: http://dx.plos.org/10.1371/

[82] Mellor AL, Munn DH. IDO expression by dendritic cells: Tolerance and tryptophan catabolism. Nature Reviews. Immunology [Internet]. 2004 Oct;**4**(10):762-774. Available

[83] Marcial GE, Ford AL, Haller MJ, Gezan SA, Harrison NA, Cai D, et al. *Lactobacillus johnsonii* N6.2 modulates the host immune responses: A double-blind, randomized trial in healthy adults. Frontiers in Immunology [Internet]. 2017;**8**:655. Available from: http://

[84] Saxton RA, Sabatini DM. mTOR signaling in growth, metabolism, and disease. Cell [Internet]. 2017 Mar;**168**(6):960-976. Available from: http://linkinghub.elsevier.com/retrieve/

[85] Laplante M, Sabatini DM. mTOR signaling at a glance. Journal of Cell Science [Internet]. 2009 Oct 15;**122**(20):3589-3594. Available from: http://jcs.biologists.org/cgi/doi/10.1242/

[86] Dibble CC, Cantley LC. Regulation of mTORC1 by PI3K signaling. Trends in Cell Biology [Internet]. 2015 Sep;**25**(9):545-555. Available from: http://linkinghub.elsevier.

[87] Düvel K, Yecies JL, Menon S, Raman P, Lipovsky AI, Souza AL, et al. Activation of a metabolic gene regulatory network downstream of mTOR complex 1. Molecular Cell [Internet]. 2010 Jul 30;**39**(2):171-183. Available from: http://www.ncbi.nlm.nih.gov/

[88] Peterson TR, Sengupta SS, Harris TE, Carmack AE, Kang SA, Balderas E, et al. mTOR complex 1 regulates lipin 1 localization to control the SREBP pathway. Cell [Internet]. 2011 Aug 5;**146**(3):408-420. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21816276

[89] Kim JE, Chen J. Regulation of peroxisome proliferator-activated receptor-gamma activity by mammalian target of rapamycin and amino acids in adipogenesis. Diabetes [Internet]. 2004 Nov;**53**(11):2748-2756. Available from: http://www.ncbi.nlm.nih.gov/

[90] Koren I, Reem E, Kimchi A. DAP1, a novel substrate of mTOR, negatively regulates autophagy. Current Biology [Internet]. 2010 Jun 22;**20**(12):1093-1098. Available from:

[91] Zinzalla V, Stracka D, Oppliger W, Hall MN. Activation of mTORC2 by association with the ribosome. Cell [Internet]. 2011 Mar 4;**144**(5):757-768. Available from: http://www.

http://www.ncbi.nlm.nih.gov/pubmed/23303207

from: http://www.ncbi.nlm.nih.gov/pubmed/15459668

www.ncbi.nlm.nih.gov/pubmed/28659913

com/retrieve/pii/S0962892415001099

http://www.ncbi.nlm.nih.gov/pubmed/20537536

ncbi.nlm.nih.gov/pubmed/21376236

journal.pone.0120779

46 Probiotics - Current Knowledge and Future Prospects

pii/S0092867417301824

pubmed/20670887

pubmed/15504954

jcs.051011


[103] Le Bacquer O, Petroulakis E, Paglialunga S, Poulin F, Richard D, Cianflone K, et al. Elevated sensitivity to diet-induced obesity and insulin resistance in mice lacking 4E-BP1 and 4E-BP2. The Journal of Clinical Investigation [Internet]. 2007 Feb 1;**117**(2):387-396. Available from: http://www.jci.org/cgi/doi/10.1172/JCI29528

[113] Stenman LK, Waget A, Garret C, Klopp P, Burcelin R, Lahtinen S. Potential probiotic *Bifidobacterium animalis* ssp. lactis 420 prevents weight gain and glucose intolerance in diet-induced obese mice. Beneficial Microbes [Internet]. 2014 Dec;**5**(4):437-445.

A Network of Physiological Interactions Modulating GI Homeostasis: Probiotics, Inflammasome…

http://dx.doi.org/10.5772/intechopen.72656

49

[114] Wang J, Tang H, Zhang C, Zhao Y, Derrien M, Rocher E, et al. Modulation of gut microbiota during probiotic-mediated attenuation of metabolic syndrome in high fat diet-fed mice. The ISME Journal [Internet]. 2015 Jan;**9**(1):1-15. Available from: http://www.ncbi.

[115] Everard A, Matamoros S, Geurts L, Delzenne NM, Cani PD. *Saccharomyces boulardii* administration changes gut microbiota and reduces hepatic steatosis, low-grade inflammation, and fat mass in obese and type 2 diabetic db/db mice. mBio [Internet]. 2014 Jun 10;**5**(3):e01011-e01014. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24917595

[116] Hulston CJ, Churnside AA, Venables MC. Probiotic supplementation prevents highfat, overfeeding-induced insulin resistance in human subjects. The British Journal of Nutrition [Internet]. 2015 Feb 28;**113**(4):596-602. Available from: http://www.ncbi.nlm.

[117] Rajkumar H, Mahmood N, Kumar M, Varikuti SR, Challa HR, Myakala SP. Effect of probiotic (VSL#3) and omega-3 on lipid profile, insulin sensitivity, inflammatory markers, and gut colonization in overweight adults: A randomized, controlled trial. Mediators of Inflammation [Internet]. 2014;**2014**:348959. Available from: http://www.

[118] Sivaprakasam S, Prasad PD, Singh N. Benefits of short-chain fatty acids and their receptors in inflammation and carcinogenesis. Pharmacology & Therapeutics [Internet]. 2016 Aug;**164**:144-151. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27113407 [119] Park J, Kim M, Kang SG, Jannasch AH, Cooper B, Patterson J, et al. Short-chain fatty acids induce both effector and regulatory T cells by suppression of histone deacetylases and regulation of the mTOR-S6K pathway. Mucosal Immunology [Internet]. 2015

Jan;**8**(1):80-93. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24917457 [120] Couteau D, McCartney AL, Gibson GR, Williamson G, Faulds CB. Isolation and characterization of human colonic bacteria able to hydrolyse chlorogenic acid. Journal of Applied Microbiology [Internet]. 2001 Jun;**90**(6):873-881. Available from: http://www.

[121] Esteban-Torres M, Reverón I, Mancheño JM, de Las Rivas B, Muñoz R. Characterization of a feruloyl esterase from *Lactobacillus plantarum*. Applied and Environmental Microbiology [Internet]. 2013 Sep;**79**(17):5130-5136. Available from: http://www.ncbi.nlm.nih.gov/

[122] Kresty LA, Weh KM, Zeyzus-Johns B, Perez LN, Howell AB. Cranberry proanthocyanidins inhibit esophageal adenocarcinoma in vitro and in vivo through pleiotropic cell death induction and PI3K/AKT/mTOR inactivation. Oncotarget [Internet]. 2015 Oct 20;**6**(32):33438-33455. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26378019

Available from: http://www.ncbi.nlm.nih.gov/pubmed/25062610

nlm.nih.gov/pubmed/24936764

nih.gov/pubmed/25630516

ncbi.nlm.nih.gov/pubmed/24795503

ncbi.nlm.nih.gov/pubmed/11412317

pubmed/23793626


[113] Stenman LK, Waget A, Garret C, Klopp P, Burcelin R, Lahtinen S. Potential probiotic *Bifidobacterium animalis* ssp. lactis 420 prevents weight gain and glucose intolerance in diet-induced obese mice. Beneficial Microbes [Internet]. 2014 Dec;**5**(4):437-445. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25062610

[103] Le Bacquer O, Petroulakis E, Paglialunga S, Poulin F, Richard D, Cianflone K, et al. Elevated sensitivity to diet-induced obesity and insulin resistance in mice lacking 4E-BP1 and 4E-BP2. The Journal of Clinical Investigation [Internet]. 2007 Feb 1;**117**(2):387-396.

[104] Kumar A, Lawrence JC, Jung DY, Ko HJ, Keller SR, Kim JK, et al. Fat cell-specific ablation of rictor in mice impairs insulin-regulated fat cell and whole-body glucose and lipid metabolism. Diabetes [Internet]. 2010 Jun;**59**(6):1397-1406. Available from: http://

[105] Li S, Brown MS, Goldstein JL. Bifurcation of insulin signaling pathway in rat liver: mTORC1 required for stimulation of lipogenesis, but not inhibition of gluconeogenesis. Proceedings of the National Academy of Sciences of the United States of America [Internet]. 2010 Feb 23;**107**(8):3441-3446. Available from: http://www.ncbi.nlm.nih.gov/

[106] Yecies JL, Zhang HH, Menon S, Liu S, Yecies D, Lipovsky AI, et al. Akt stimulates hepatic SREBP1c and lipogenesis through parallel mTORC1-dependent and independent pathways. Cell Metabolism [Internet]. 2011 Jul;**14**(1):21-32. Available from: http://

[107] Li J, Yen C, Liaw D, Podsypanina K, Bose S, Wang SI, et al. PTEN, a putative protein tyrosine phosphatase gene mutated in human brain, breast, and prostate cancer. Science [Internet]. 1997 Mar 28;**275**(5308):1943-1947. Available from: http://www.ncbi.

[108] Johnson SR, Tattersfield AE. Lymphangioleiomyomatosis. Seminars in Respiratory and Critical Care Medicine [Internet]. 2002 Apr;**23**(2):85-92. Available from: http://www.

[109] Sato T, Nakashima A, Guo L, Coffman K, Tamanoi F. Single amino-acid changes that confer constitutive activation of mTOR are discovered in human cancer. Oncogene [Internet]. 2010 May 6;**29**(18):2746-2752. Available from: http://www.ncbi.nlm.nih.gov/

[110] Lee D-F, Kuo H-P, Chen C-T, Hsu J-M, Chou C-K, Wei Y, et al. IKKβ suppression of TSC1 links inflammation and tumor angiogenesis via the mTOR pathway. Cell [Internet]. 2007 Aug;**130**(3):440-455. Available from: http://linkinghub.elsevier.com/retrieve/pii/

[111] Arkan MC, Hevener AL, Greten FR, Maeda S, Li Z-W, Long JM, et al. IKK-beta links inflammation to obesity-induced insulin resistance. Nature Medicine [Internet]. 2005 Feb;**11**(2):191-198. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15685170

[112] Mencarelli A, Distrutti E, Renga B, D'Amore C, Cipriani S, Palladino G, et al. Probiotics modulate intestinal expression of nuclear receptor and provide counter-regulatory signals to inflammation-driven adipose tissue activation. PLoS One [Internet]. 2011;

**6**(7):e22978. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21829567

Available from: http://www.jci.org/cgi/doi/10.1172/JCI29528

linkinghub.elsevier.com/retrieve/pii/S1550413111002208

www.ncbi.nlm.nih.gov/pubmed/20332342

pubmed/20133650

48 Probiotics - Current Knowledge and Future Prospects

pubmed/20190810

S0092867407007623

nlm.nih.gov/pubmed/9072974

ncbi.nlm.nih.gov/pubmed/16088601


[123] Zhang Y, Xu S, Lin J, Yao G, Han Z, Liang B, et al. mTORC1 is a target of nordihydroguaiaretic acid to prevent breast tumor growth in vitro and in vivo. Breast Cancer Research and Treatment [Internet]. 2012 Nov;**136**(2):379-388. Available from: http:// www.ncbi.nlm.nih.gov/pubmed/23053656

**Chapter 3**

**Provisional chapter**

**Probiotics and Its Relationship with the Cardiovascular**

**Probiotics and Its Relationship with the Cardiovascular** 

Cardiovascular disease is a major health issue worldwide. Individuals who have cardiovascular disease, are often at risk or already have other diseases, which together can lead to metabolic syndromes and possibly increase the risk of morbidity and mortality. Gut microbial balance is increasingly being recognized as a possible risk factor in cardiovascular illnesses. Studies published so far have shown a possible link to hypertension, hyperlipidemia and associated cardiac illnesses. Balance of the colonic flora seems to improve these co-morbid conditions. Probiotics have been studied in several studies to determine if their use provides a beneficial non-pharmacological treatment option for diseases such as diabetes, obesity, hypercholesterolemia, hypertension, chronic kidney disease, cardiomyopathy and atherosclerosis. Placebo, double blinded controlled studies are s needed to determine if these perceived beneficial effects exists and to what extent

**Keywords:** probiotics, cardiovascular health, hypertension, obesity, diabetes mellitus

Cardiovascular disease (CVD) is a major cause of death worldwide. There are disease-associated risks that can be either modifiable or unmodifiable factors and examples are low-density lipoprotein (LDL) cholesterol, increased triglyceride-rich lipoproteins, and low levels of highdensity lipoprotein (HDL) cholesterol [13]. An individual's personal gene makeup, body composition, health, and having certain preexisting disease states can also influence their risk of having a CVD. These factors often contribute to a group of conditions leading to metabolic

probiotics play in the overall outcome in cardiovascular diseases.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

DOI: 10.5772/intechopen.75077

**System**

**System**

Suresh Antony and Marlina Ponce de Leon

Suresh Antony and Marlina Ponce de Leon

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.75077

**Abstract**

**1. Introduction**


#### **Probiotics and Its Relationship with the Cardiovascular System Probiotics and Its Relationship with the Cardiovascular System**

DOI: 10.5772/intechopen.75077

[123] Zhang Y, Xu S, Lin J, Yao G, Han Z, Liang B, et al. mTORC1 is a target of nordihydroguaiaretic acid to prevent breast tumor growth in vitro and in vivo. Breast Cancer Research and Treatment [Internet]. 2012 Nov;**136**(2):379-388. Available from: http://

[124] Neis E, Dejong C, Rensen S. The role of microbial amino acid metabolism in host metabolism. Nutrients [Internet]. 2015 Apr 16;**7**(4):2930-2946. Available from: http://www.

[125] Ban H, Shigemitsu K, Yamatsuji T, Haisa M, Nakajo T, Takaoka M, et al. Arginine and Leucine regulate p70 S6 kinase and 4E-BP1 in intestinal epithelial cells. International Journal of Molecular Medicine [Internet]. 2004 Apr;**13**(4):537-543. Available from: http://

[126] Dai Z-L, Zhang J, Wu G, Zhu W-Y. Utilization of amino acids by bacteria from the pig small intestine. Amino Acids [Internet]. 2010 Nov;**39**(5):1201-1215. Available from:

[127] Evenepoel P, Claus D, Geypens B, Hiele M, Geboes K, Rutgeerts P, et al. Amount and fate of egg protein escaping assimilation in the small intestine of humans. The American Journal of Physiology [Internet]. 1999 Nov;**277**(5 Pt 1):G935-G943. Available

[128] Dai Z-L, Wu G, Zhu W-Y. Amino acid metabolism in intestinal bacteria: Links between gut ecology and host health. Frontiers in Bioscience (Landmark Edition) [Internet]. 2011 Jan 1;**16**:1768-1786. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21196263

[129] Metz R, Rust S, Duhadaway JB, Mautino MR, Munn DH, Vahanian NN, et al. IDO inhibits a tryptophan sufficiency signal that stimulates mTOR: A novel IDO effector pathway targeted by D-1-methyl-tryptophan. Oncoimmunology [Internet]. 2012 Dec 1;**1**(9):1460-1468. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23264892

www.ncbi.nlm.nih.gov/pubmed/23053656

www.ncbi.nlm.nih.gov/pubmed/15010853

http://www.ncbi.nlm.nih.gov/pubmed/20300787

from: http://www.ncbi.nlm.nih.gov/pubmed/10564098

mdpi.com/2072-6643/7/4/2930/

50 Probiotics - Current Knowledge and Future Prospects

Suresh Antony and Marlina Ponce de Leon Suresh Antony and Marlina Ponce de Leon

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.75077

#### **Abstract**

Cardiovascular disease is a major health issue worldwide. Individuals who have cardiovascular disease, are often at risk or already have other diseases, which together can lead to metabolic syndromes and possibly increase the risk of morbidity and mortality. Gut microbial balance is increasingly being recognized as a possible risk factor in cardiovascular illnesses. Studies published so far have shown a possible link to hypertension, hyperlipidemia and associated cardiac illnesses. Balance of the colonic flora seems to improve these co-morbid conditions. Probiotics have been studied in several studies to determine if their use provides a beneficial non-pharmacological treatment option for diseases such as diabetes, obesity, hypercholesterolemia, hypertension, chronic kidney disease, cardiomyopathy and atherosclerosis. Placebo, double blinded controlled studies are s needed to determine if these perceived beneficial effects exists and to what extent probiotics play in the overall outcome in cardiovascular diseases.

**Keywords:** probiotics, cardiovascular health, hypertension, obesity, diabetes mellitus

#### **1. Introduction**

Cardiovascular disease (CVD) is a major cause of death worldwide. There are disease-associated risks that can be either modifiable or unmodifiable factors and examples are low-density lipoprotein (LDL) cholesterol, increased triglyceride-rich lipoproteins, and low levels of highdensity lipoprotein (HDL) cholesterol [13]. An individual's personal gene makeup, body composition, health, and having certain preexisting disease states can also influence their risk of having a CVD. These factors often contribute to a group of conditions leading to metabolic

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

syndrome. Metabolic syndrome increases an individual's chance of having a disease such as CVD and/or diabetes.

Probiotics have been observed to have a positive effect on gut microbial and are often studied

Probiotics and Its Relationship with the Cardiovascular System

http://dx.doi.org/10.5772/intechopen.75077

53

Some examples of the positive outcome from probiotics have been an improved immune system through immunoglobulin production, trigger cell-mediated immune response, and help in the treatment of gut disorders such as irritable bowel syndrome (IBS), *Clostridium difficile* colitis, gastric ulcers lactose intolerance, and antibiotic-associated diarrhea (AAD). Positive results from probiotics are caused by the multifactorial process related to them that results in the production of organic acids, hydrogen peroxide, bacteriocins, bacteriocin-link inhibitory substances, short-chain fatty acid (SCFA)-conjugated linoleic acid, and ϒ-amino butyric acid [8]. These can cause improvements that range from improved bone density, anxiety, hyperammonemia, and improved blood lipid profile to name a few [3]. This is based on the proven functions of probiotics such as balancing intestinal microbiota, modulating the immune sys-

Prebiotics often provided with probiotics can contribute to the influences on the bacteria population in the human gut [7, 9]. Prebiotics is a type of nondigestible fiber compound, which is able to bypass the upper gastrointestinal tract, remain undigested, and reach the colon where they are fermented by the gut microflora. It is a type of food source for probiotics (microbiota) and it regulates the growth and activity of gut microbiota, resulting in an improved gut health and strengthened immune system [7, 14]. In order for prebiotics to provide a beneficial role, they must have the following three characteristics: "resistance to gastric acidity, hydrolysis by mammalian enzyme, and gastrointestinal absorption, fermentation by intestinal microflora and selective stimulation of growth and/or activity of intestinal bacteria associated with health and well-being." Various chain-length oligosaccharides are the most common that are studied and those include fructo-oligosaccharide and galacto-oligosaccharide/transgalactooligosaccharides [2, 7]. Tri-, di-, and some monosaccharides may also be used as prebiotics if

Prebiotics mode of action is taking advantage of the commensals that are already in the host; they use this to degrade their otherwise indigestible bonds, which support the microbial survival [1]. They are used as fermented ingredients that induce the growth or activity of microorganism. *Bifidobacterium* and *Lactobacillus* have been identified for responding to the administration of prebiotics, for example, oligofructose (OFS) stimulates the growth of *Bifidobacterium*. Prebiotics beneficial properties are not just limited to the GI system. Once prebiotics have been selective fermentation, there will be an increase in the number of commensals while lowering other neutral/harmful organisms which support symbiotic gut microbiota composition. It has been shown that though the "gut-brain axis," some such as fructo-oligosaccharide and galacto-oligosaccharide are able to modulate neural growth factors such as brainderived neurotrophic factors and synaptic proteins [2]. This can affect memory, attention, learning, and mood. When prebiotics and probiotics are used together, it is called synbiotics. Fermented foods consist of microorganisms that are either functioning or nonfunctioning. One of the functioning actions is to stimulate probiotic function [6]. *Enterococcus*, *Lactobacillus*, *Lactococcus*, *Leuconostoc*, *Pediococcus*, and *Weissella* are lactic acid bacteria associated with fermented food along with species of *Bacillus*, *Bifidobacterium*, *Brachybacterium*, *Brevibacterium*,

in a combined relationship with prebiotics termed symbiotic.

tem, and exerting metabolic influences [4].

they have host-indigestible bonds.

Gut microbes are thought to be responsible for healthy outcomes in terms of the gastrointestinal (GI) tract, as well as positive health benefits distant to the GI tract. The alteration to dietary macronutrient ingestion has increased the prevalence of metabolic disorders which has been shown to be related to microbial imbalance to the gut as part of the pathogenesis [7, 9]. A meta-analysis of several studies found about 1100 bacteria species and their related properties in relation to diseases such as diabetes mellitus, cardiovascular disease, obesity, and cancer [7]. The change in gut microbe related to a disease state can often be associated with an individual's diet. Diets that are high in fat and/or sugar and low in fiber have a negative effect on gut ecosystem [18]. Therefore, diet modification to alter the composition of gut bacteria is vital for either prophylaxis or the treatment of some diseases. This makes gut microenvironment a focus point in the prevention of unhealthy state and improvement to a healthy state in order to avoid metabolic syndrome-related diseases such as cardiovascular disease and diabetes.

Modifying gut microbiota with probiotics has been in practice for centuries and is now being studied in relation to treatment and/or prophylaxis for metabolic syndrome and related diseases such as cardiovascular disease [9]. The more recent metagenomics studies are those that have demonstrated that probiotics are involved in host immune modulation and influence the development and physiology of organs. Therefore, they have been identified as the possible medical therapies to treat GI disorders and to restore an impaired gut ecosystem [8]. Studies have strengthened the idea of the importance of probiotics in aiding the prevention and prophylaxis of gut disorders, urogenital, and respiratory infections with their results [8]. The hypothesis that they could aid in the fight against metabolic disorders is based on them having an effect on the modulation of composition and function of interstitial microbiota [7]. Background information on probiotics, as well as current studies that have observed the gut microbiota in cardiovascular disease-related conditions such as obesity, diabetic, hypercholesterolemia, hypertension, cardio-arterial disease, and cardiomyopathy based on past studies, has been analyzed.

#### **2. Probiotics**

Individuals using probiotics for the improvement of health have a well-known history, especially lactic acid bacteria (LAB) and *Bifidobacteria*, as well as prebiotics as part of food or fermented food [7, 20]. Dating back to 76 BC, there was the recommendation of ingestion of fermented milk products for those who had gastroenteritis [7]. The idea behind probiotics being used as a way to alter interstitial microbial balance started in the twentieth century from the work of Metchnikoff [7, 9]. With new advance techniques such as DNA-based analyses, there have been a significant number of research that observed different bacteria and their properties that are related to both positive and negative influences on the human body in the disease and healthy state [7]. The following has been stated to be important in probiotic research: identification, maintenance, and characterization of probiotic strains in live conditions, so potency is preserved, and they arrive alive in a state of action which varies [25]. Probiotics have been observed to have a positive effect on gut microbial and are often studied in a combined relationship with prebiotics termed symbiotic.

syndrome. Metabolic syndrome increases an individual's chance of having a disease such as

Gut microbes are thought to be responsible for healthy outcomes in terms of the gastrointestinal (GI) tract, as well as positive health benefits distant to the GI tract. The alteration to dietary macronutrient ingestion has increased the prevalence of metabolic disorders which has been shown to be related to microbial imbalance to the gut as part of the pathogenesis [7, 9]. A meta-analysis of several studies found about 1100 bacteria species and their related properties in relation to diseases such as diabetes mellitus, cardiovascular disease, obesity, and cancer [7]. The change in gut microbe related to a disease state can often be associated with an individual's diet. Diets that are high in fat and/or sugar and low in fiber have a negative effect on gut ecosystem [18]. Therefore, diet modification to alter the composition of gut bacteria is vital for either prophylaxis or the treatment of some diseases. This makes gut microenvironment a focus point in the prevention of unhealthy state and improvement to a healthy state in order to avoid metabolic syndrome-related diseases such as cardiovascular disease and diabetes. Modifying gut microbiota with probiotics has been in practice for centuries and is now being studied in relation to treatment and/or prophylaxis for metabolic syndrome and related diseases such as cardiovascular disease [9]. The more recent metagenomics studies are those that have demonstrated that probiotics are involved in host immune modulation and influence the development and physiology of organs. Therefore, they have been identified as the possible medical therapies to treat GI disorders and to restore an impaired gut ecosystem [8]. Studies have strengthened the idea of the importance of probiotics in aiding the prevention and prophylaxis of gut disorders, urogenital, and respiratory infections with their results [8]. The hypothesis that they could aid in the fight against metabolic disorders is based on them having an effect on the modulation of composition and function of interstitial microbiota [7]. Background information on probiotics, as well as current studies that have observed the gut microbiota in cardiovascular disease-related conditions such as obesity, diabetic, hypercholesterolemia, hypertension, cardio-arterial disease, and cardiomyopathy based on past stud-

Individuals using probiotics for the improvement of health have a well-known history, especially lactic acid bacteria (LAB) and *Bifidobacteria*, as well as prebiotics as part of food or fermented food [7, 20]. Dating back to 76 BC, there was the recommendation of ingestion of fermented milk products for those who had gastroenteritis [7]. The idea behind probiotics being used as a way to alter interstitial microbial balance started in the twentieth century from the work of Metchnikoff [7, 9]. With new advance techniques such as DNA-based analyses, there have been a significant number of research that observed different bacteria and their properties that are related to both positive and negative influences on the human body in the disease and healthy state [7]. The following has been stated to be important in probiotic research: identification, maintenance, and characterization of probiotic strains in live conditions, so potency is preserved, and they arrive alive in a state of action which varies [25].

CVD and/or diabetes.

52 Probiotics - Current Knowledge and Future Prospects

ies, has been analyzed.

**2. Probiotics**

Some examples of the positive outcome from probiotics have been an improved immune system through immunoglobulin production, trigger cell-mediated immune response, and help in the treatment of gut disorders such as irritable bowel syndrome (IBS), *Clostridium difficile* colitis, gastric ulcers lactose intolerance, and antibiotic-associated diarrhea (AAD). Positive results from probiotics are caused by the multifactorial process related to them that results in the production of organic acids, hydrogen peroxide, bacteriocins, bacteriocin-link inhibitory substances, short-chain fatty acid (SCFA)-conjugated linoleic acid, and ϒ-amino butyric acid [8]. These can cause improvements that range from improved bone density, anxiety, hyperammonemia, and improved blood lipid profile to name a few [3]. This is based on the proven functions of probiotics such as balancing intestinal microbiota, modulating the immune system, and exerting metabolic influences [4].

Prebiotics often provided with probiotics can contribute to the influences on the bacteria population in the human gut [7, 9]. Prebiotics is a type of nondigestible fiber compound, which is able to bypass the upper gastrointestinal tract, remain undigested, and reach the colon where they are fermented by the gut microflora. It is a type of food source for probiotics (microbiota) and it regulates the growth and activity of gut microbiota, resulting in an improved gut health and strengthened immune system [7, 14]. In order for prebiotics to provide a beneficial role, they must have the following three characteristics: "resistance to gastric acidity, hydrolysis by mammalian enzyme, and gastrointestinal absorption, fermentation by intestinal microflora and selective stimulation of growth and/or activity of intestinal bacteria associated with health and well-being." Various chain-length oligosaccharides are the most common that are studied and those include fructo-oligosaccharide and galacto-oligosaccharide/transgalactooligosaccharides [2, 7]. Tri-, di-, and some monosaccharides may also be used as prebiotics if they have host-indigestible bonds.

Prebiotics mode of action is taking advantage of the commensals that are already in the host; they use this to degrade their otherwise indigestible bonds, which support the microbial survival [1]. They are used as fermented ingredients that induce the growth or activity of microorganism. *Bifidobacterium* and *Lactobacillus* have been identified for responding to the administration of prebiotics, for example, oligofructose (OFS) stimulates the growth of *Bifidobacterium*. Prebiotics beneficial properties are not just limited to the GI system. Once prebiotics have been selective fermentation, there will be an increase in the number of commensals while lowering other neutral/harmful organisms which support symbiotic gut microbiota composition. It has been shown that though the "gut-brain axis," some such as fructo-oligosaccharide and galacto-oligosaccharide are able to modulate neural growth factors such as brainderived neurotrophic factors and synaptic proteins [2]. This can affect memory, attention, learning, and mood. When prebiotics and probiotics are used together, it is called synbiotics.

Fermented foods consist of microorganisms that are either functioning or nonfunctioning. One of the functioning actions is to stimulate probiotic function [6]. *Enterococcus*, *Lactobacillus*, *Lactococcus*, *Leuconostoc*, *Pediococcus*, and *Weissella* are lactic acid bacteria associated with fermented food along with species of *Bacillus*, *Bifidobacterium*, *Brachybacterium*, *Brevibacterium*, and *Probacterium* [6]. *Lactobacillus* and *Enterococcus* are LABs, which with *Bifidobacterium* are the most commonly used probiotics. The most common traditional source of the probiotic *Lactobacilli* is fermented milk [6]. These microorganisms have several properties such as probiotic, antimicrobial, antioxidant, peptide production, fibrinolytic activity, poly-glutamic acid, degradation of antinutritive compounds, and ambrotose complex memory [6]. *Bifidobacterium* and *Lactobacilli* will selectively ferment prebiotics which cause an increase of these commensals while displacing other pathogenic or neutral organisms [2].

[5]. Some of the effects of altered bacteria composition in the gut is linked to obesity due to several changes such as downregulated activity of FIAF and AMK, impaired production of SCFAs, increased inflammation, altered LPS-endocannabinoid (eCB) system regulatory loops, and bile acid metabolism [5]. The cause of the alteration is believed to be linked through the host's diet. An example of this is that there was a reduction in *Lactobacillus* and *Bifidobacterium* and was observed in mice when they consumed high-fat diets [5]. This change of environment is the basis of studies that have shown that gut microbiota plays a role in energy homeostasis

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In obese individuals, the different microorganism environment is believed to affect adiposity and alter the regulation to fat storage [7]. Insulin-type fructan affects the gut ecology and stimulates immune cells leading to a decrease in the weight gain and fat mass in obese individuals [7]. In a meta-analysis, several studies found that there was an increased prevalence of *Firmicutes* shown with obesity phenotypes. These bacteria interfere in a negative relation with metabolism and insulin sensitivity [26]. Probiotics, while resulting in more subtle effects in humans versus mice studies, are now being studied as a way to modulate gut microbiota in relation to obesity [20]. This is because certain traits in probiotic cultures such as exopolysaccharides, CLA, and GABA production were found to have a positive effect on host lipid

An increased number of *Lachnospiraceae* family in obese female microbiota were altered when probiotics containing *L. rhamnosus* CGMCC1.3724 (which reduces *Lachnospiraceae* family) were administered along with an energy-strict diet [38]. However, the probiotics that were related to fat mass in Ref. [38] also caused a decrease of leptin levels, which may lead to a need for the supplementation of leptin in order to maintain weight loss. Probiotics and weight loss have also been linked to a decrease in ghrelin, which could assist in maintaining the weight loss even with the loss of leptin [41]. When *L. gasseri* strain was given in fermented milk for 12 weeks, there was a decrease in abdominal visceral fat in adults with large visceral fat areas [18]. Supporting this, there have been other studies that when looked at the outcome of probiotic consumption, there was a decrease in both body mass index (BMI) and waist circumferences [13]. However, those were a limited number of studies, and additional studies are required, including those that will observe the effect of probiotics on energy balance-related hormones. In multi-strain probiotic therapies, with 8 weeks of treatment, obese individuals showed a decreased weight, waist circumference, and serum cholesterol levels. This study also supported the idea that probiotics caused results not only by their own metabolism but through probiotic alteration of the gut microbe with an increase of *L. plantarum* population and other Gram-negative bacteria [20]. When prebiotics were added, there was control of overexpression of several host genes that have been known to be related to both adiposity and inflammation [27]. However, the altered level in gut microbe with one probiotic only had a subtle effect, and more studies are necessary to understand if and what probiotics provide a change

Gut bacteria also play a role in obesity through the regulation of inflammation. The relation between low-grade systemic inflammation and obesity is weakened through peptides produced in the gut. These peptides' synthesis is affected by the composition of gut microbiota [7].

and bodyweight, therefore affecting the pathophysiology of obesity [5, 18].

metabolism and gut microbial composition [8].

to obese individual's gut microbe.

Probiotics containing a live microorganism should be used with caution in patients that are immunocompromised because they can cause infection or pathogenic colonization [27]. This has been supported by several studies. A study that observed renal-transplant patients with AIDS found that Lactobacillemia, which is not a common cause of bacteremia, occurred. Lactobacillemia was found in other patients who were immunocompromised with the following conditions: cancer, organ transplantation, diabetes mellitus, and recent surgery. Out of these patients, fever was presented in all of them and 15% developed sepsis but it is important to note that Lactobacillemia can have a wide range of clinical features. A probiotic consumed by a patient who had advanced and severe bicuspid aortic valve stenosis developed *L. paracasei* endocarditis. *Lactobacillus* may be under recorded because it is not observed as a pathogen and is also usually determined as part of a polymicrobial infection [33]. These are just a few cases in which an infection was caused, and overall, there have been studies that support the safety of probiotics consumed by groups of immunocompromised patients [33]. Probiotics can also affect some interaction with other drugs, for example, they could interfere with the production of vitamin K and therefore could affect the sensitivity to some drugs like warfarin [27].

Lactic acid bacteria tend to produce bioactive compounds, which are frequently found in fermented products due to LAB-elective habitant food, especially in diary. Biogenic amines are the main health risk in fermented food [5]. These compounds can sometimes cause allergies, hypertensive crises, and headaches. Also, it is important to make sure that probiotics, which are used to aid in the control of LDL levels, do not affect cardiac myocyte function, increase fat deposition, or cause cancer [20]. Cancer is a risk because secondary bile salts may disrupt DNA repair pathway. This disruption can lead to oxidative stress in epithelial cells which can start tumor formation [21]. These adverse effects on human are usually not a concern in generally healthy individuals [6].

#### **3. Relationship of CVS to probiotic use**

#### **3.1. Obesity**

Obesity, which causes a low-grade inflammation, is a risk factor for cardiovascular disease, diabetes, dyslipidemia, premature death, hepatobiliary disease, and several cancers. There is an estimate of 1.7 billion people in the world that are overweight. Obese individuals tend to have an altered composition of intestinal microbiota, which suggest that intestinal microbiocenosis can be considered the environmental factor that creates the development of obesity [5]. Some of the effects of altered bacteria composition in the gut is linked to obesity due to several changes such as downregulated activity of FIAF and AMK, impaired production of SCFAs, increased inflammation, altered LPS-endocannabinoid (eCB) system regulatory loops, and bile acid metabolism [5]. The cause of the alteration is believed to be linked through the host's diet. An example of this is that there was a reduction in *Lactobacillus* and *Bifidobacterium* and was observed in mice when they consumed high-fat diets [5]. This change of environment is the basis of studies that have shown that gut microbiota plays a role in energy homeostasis and bodyweight, therefore affecting the pathophysiology of obesity [5, 18].

and *Probacterium* [6]. *Lactobacillus* and *Enterococcus* are LABs, which with *Bifidobacterium* are the most commonly used probiotics. The most common traditional source of the probiotic *Lactobacilli* is fermented milk [6]. These microorganisms have several properties such as probiotic, antimicrobial, antioxidant, peptide production, fibrinolytic activity, poly-glutamic acid, degradation of antinutritive compounds, and ambrotose complex memory [6]. *Bifidobacterium* and *Lactobacilli* will selectively ferment prebiotics which cause an increase of these commen-

Probiotics containing a live microorganism should be used with caution in patients that are immunocompromised because they can cause infection or pathogenic colonization [27]. This has been supported by several studies. A study that observed renal-transplant patients with AIDS found that Lactobacillemia, which is not a common cause of bacteremia, occurred. Lactobacillemia was found in other patients who were immunocompromised with the following conditions: cancer, organ transplantation, diabetes mellitus, and recent surgery. Out of these patients, fever was presented in all of them and 15% developed sepsis but it is important to note that Lactobacillemia can have a wide range of clinical features. A probiotic consumed by a patient who had advanced and severe bicuspid aortic valve stenosis developed *L. paracasei* endocarditis. *Lactobacillus* may be under recorded because it is not observed as a pathogen and is also usually determined as part of a polymicrobial infection [33]. These are just a few cases in which an infection was caused, and overall, there have been studies that support the safety of probiotics consumed by groups of immunocompromised patients [33]. Probiotics can also affect some interaction with other drugs, for example, they could interfere with the production of vitamin K and therefore could affect the sensitivity to some drugs like

Lactic acid bacteria tend to produce bioactive compounds, which are frequently found in fermented products due to LAB-elective habitant food, especially in diary. Biogenic amines are the main health risk in fermented food [5]. These compounds can sometimes cause allergies, hypertensive crises, and headaches. Also, it is important to make sure that probiotics, which are used to aid in the control of LDL levels, do not affect cardiac myocyte function, increase fat deposition, or cause cancer [20]. Cancer is a risk because secondary bile salts may disrupt DNA repair pathway. This disruption can lead to oxidative stress in epithelial cells which can start tumor formation [21]. These adverse effects on human are usually not a concern in

Obesity, which causes a low-grade inflammation, is a risk factor for cardiovascular disease, diabetes, dyslipidemia, premature death, hepatobiliary disease, and several cancers. There is an estimate of 1.7 billion people in the world that are overweight. Obese individuals tend to have an altered composition of intestinal microbiota, which suggest that intestinal microbiocenosis can be considered the environmental factor that creates the development of obesity

sals while displacing other pathogenic or neutral organisms [2].

54 Probiotics - Current Knowledge and Future Prospects

warfarin [27].

**3.1. Obesity**

generally healthy individuals [6].

**3. Relationship of CVS to probiotic use**

In obese individuals, the different microorganism environment is believed to affect adiposity and alter the regulation to fat storage [7]. Insulin-type fructan affects the gut ecology and stimulates immune cells leading to a decrease in the weight gain and fat mass in obese individuals [7]. In a meta-analysis, several studies found that there was an increased prevalence of *Firmicutes* shown with obesity phenotypes. These bacteria interfere in a negative relation with metabolism and insulin sensitivity [26]. Probiotics, while resulting in more subtle effects in humans versus mice studies, are now being studied as a way to modulate gut microbiota in relation to obesity [20]. This is because certain traits in probiotic cultures such as exopolysaccharides, CLA, and GABA production were found to have a positive effect on host lipid metabolism and gut microbial composition [8].

An increased number of *Lachnospiraceae* family in obese female microbiota were altered when probiotics containing *L. rhamnosus* CGMCC1.3724 (which reduces *Lachnospiraceae* family) were administered along with an energy-strict diet [38]. However, the probiotics that were related to fat mass in Ref. [38] also caused a decrease of leptin levels, which may lead to a need for the supplementation of leptin in order to maintain weight loss. Probiotics and weight loss have also been linked to a decrease in ghrelin, which could assist in maintaining the weight loss even with the loss of leptin [41]. When *L. gasseri* strain was given in fermented milk for 12 weeks, there was a decrease in abdominal visceral fat in adults with large visceral fat areas [18]. Supporting this, there have been other studies that when looked at the outcome of probiotic consumption, there was a decrease in both body mass index (BMI) and waist circumferences [13]. However, those were a limited number of studies, and additional studies are required, including those that will observe the effect of probiotics on energy balance-related hormones.

In multi-strain probiotic therapies, with 8 weeks of treatment, obese individuals showed a decreased weight, waist circumference, and serum cholesterol levels. This study also supported the idea that probiotics caused results not only by their own metabolism but through probiotic alteration of the gut microbe with an increase of *L. plantarum* population and other Gram-negative bacteria [20]. When prebiotics were added, there was control of overexpression of several host genes that have been known to be related to both adiposity and inflammation [27]. However, the altered level in gut microbe with one probiotic only had a subtle effect, and more studies are necessary to understand if and what probiotics provide a change to obese individual's gut microbe.

Gut bacteria also play a role in obesity through the regulation of inflammation. The relation between low-grade systemic inflammation and obesity is weakened through peptides produced in the gut. These peptides' synthesis is affected by the composition of gut microbiota [7]. An example of this is the serum amyloid A3 protein where the expression in adipose tissue is regulated by gut microbiota [7]. Any alteration to the gut microbiota could then also potentially play a role in body weight due to intestinal microbiota effects on adiposity and the regulation of fat storages.

diabetes mellitus [1]. The first line of treatment is proper nutrition and physical activity [1]. Probiotic supplements along with prebiotics were found to improve the hyperglycemia state. When multi-strain probiotics along with symbiotic supplements were provided to individuals in a hyperglycemia state as their baseline, there was an improvement in their blood glucose level (BGL) [1]. Glucose tolerance and increased satiety with weight loss were found when individuals were administered OFS which lead to *Bifidobacterium* and endotoxin levels to be normalized. Butyrate, which has properties of propionate that can lower blood glucose, is produced by several bacteria [4]. Other studies found that with a symbiotic shake of *L. acidophilus*, *Bifidobacterium* and *L. rhamnosus* caused a 38% decrease in blood glucose levels for patients with T2DM. Though these studies demonstrate that supplementation with probiotics with symbiotic may help in the control of hyperglycemia and T2DM, larger studies are needed to confirm. The glucose-lowering effect is due to the metabolites of these bacteria which was shown to affect biological signaling pathways, modulated genes involved in ubiquitination and proteasome process, and altered autonomic nerve activity [1]. It is also vital to note that probiotics or

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synbiotic alone did not cause a significant reduction in fasting blood glucose levels.

trace which was found to cause cholesterol-lowering effects in vivo.

been observed to lower cholesterol both in vitro and in vivo [28].

Cardiovascular disease, affecting both blood vessels and/or heart, usually is the result of hypercholesterolemia and dyslipidemia. There have not been direct studies that compare the effect of prebiotic intake on cardiovascular health; however, there has been an observation on the serum lipid profiles, which all have an effect on CV [2]. These experiments have observed the effect of probiotics and/or prebiotics both in vitro and in vivo on lowering cholesterol [7]. In order to use probiotics to help lower cholesterol, the probiotics adhesion property to the human intestinal epithelial cells is a critical characteristic that must be considered [14]. This characteristic is to ensure that there is extended probiotic transit time in the gastrointestinal

Studies have shown a lower low-density lipoprotein and total cholesterol, along with increases in high-density lipoprotein cholesterol, a reduction in systolic blood pressure (SBP), increases in antioxidant activity, and influences on leptin regulation as a result of probiotics [9]. This is done through an enzyme called bile salt hydrolase (BSH) which causes a decrease in the absorption of cholesterol in the blood stream and is an essential criterion for the selection of probacteria [9, 13]. This enzyme unconjugated bile acids, which eventually cause a decrease in circulating triglycerides and plasma LDL and VLDL levels [12, 20]. The most associated BSH active probiotics are *Lactobacillus*, *Lactococcus,* and *Bifidobacterium* [21]. These bacteria have

For example, see [14], which found that *L. fermentum* NCIMB 5221 and NCIMB 2797 were able to lower cholesterol in an in vitro analysis. They found that *L. plantarum* ATC 14917 had the best results [22]. Another study found that the BSH candidate *L. reuteri* NCIMB 30242 had the capabilities to lower cholesterol in otherwise healthy individuals [12]. This is because *Lactobacillus* species are able to colonize and survive in small intestines [21]. These studies have demonstrated why lactic acid bacteria with BSH are being classified as having hypocholesterol effect. More specifically, trials that used multiple strains versus single strains and fermented products

**3.3. Hypercholesterolemia**

#### **3.2. Diabetes**

Having diabetes or having the risk of diabetes is often associated with a higher risk for cardiovascular disease. This is because of a compensatory action resulting in hyperinsulinemia which leads to a variety of metabolic abnormalities. Individuals who have diabetes were found to have altered intestinal microbiota which can cause increased adiposity, B-cell dysfunction, metabolic endotoxemia, systemic inflammation, and oxidative stress related to their disease. SCFA is an important function in type 2 diabetes mellitus (T2DM); however, bacteria producing SCFA numbers are lower in diabetic individual [7]. Probiotics may offer a beneficial therapy for diabetic patients through increasing SCFA and other methods.

Oral supplements, which contained viable and freeze-dried stains, were found to reduce fasting plasma glucose when compared to a placebo group. Fermented food was also noted to not only aid in the prevention of diabetes but also cause favorable changes in those already diagnosed with diabetes [6]. This could be due to some probiotics delaying the glucose intolerance and hyperglycemia state in individuals. For those with diabetes, some probiotics in fermented food decrease insulin requirements and could increase insulin sensitivity for nondiabetics [6].

Diabetes has a connection to long-term inflammation. This is due to the consumption of high fats and high fructose which causes chronic inflammation leading to the induction of insulin resistance (IR) and disruption of gut flora. This is supported by studies, which have found that certain diets, for example, high-fat diets, tend to increase lipopolysaccharide (LPS) contained in gut microbiota which leads to a decrease of *Bifidobacteria*. This leads to an inflammation state which may be associated to insulin resistance and weight gain [1]. Different probiotics have differential immune pro- or anti-inflammatory action through the attenuation of nuclear factor kappa B (NF-kB) [4]. *Lactobacillus* is a lactic acid bacteria that contains immune stimulating properties [28]. Probiotics, *L. reuteri,* and *L. plantarum* have anti-inflammatory and antioxidant effects which can aid in the management of diabetes [9]. For example, C-reactive protein (CRP), an inflammation marker, is noted to decrease when these probiotic supplements are used [13].

In a meta-analysis, there was no statistically significant glucose-lowering effect of probiotics when combined with prebiotics [1]. However, prebiotics may affect the inflammation state due to prebiotics having immunomodulatory benefits. In a study, prebiotics were found to alleviate chronic inflammation, which could lower the risk of development of cardiovascular disease and diabetes [2]. Probiotics may even possibly assist in the prevention of diabetes through bacterial translocation to mesenteric adipose tissue. This is mediated through acetate production and an increase in gut epithelial integrity [26].

Hyperglycemia, which is a property of diabetes, is a term given when a person has continuous high-fasting blood glucose (>6.1) and is associated with different diseases, the main one being diabetes mellitus [1]. The first line of treatment is proper nutrition and physical activity [1]. Probiotic supplements along with prebiotics were found to improve the hyperglycemia state. When multi-strain probiotics along with symbiotic supplements were provided to individuals in a hyperglycemia state as their baseline, there was an improvement in their blood glucose level (BGL) [1]. Glucose tolerance and increased satiety with weight loss were found when individuals were administered OFS which lead to *Bifidobacterium* and endotoxin levels to be normalized. Butyrate, which has properties of propionate that can lower blood glucose, is produced by several bacteria [4]. Other studies found that with a symbiotic shake of *L. acidophilus*, *Bifidobacterium* and *L. rhamnosus* caused a 38% decrease in blood glucose levels for patients with T2DM. Though these studies demonstrate that supplementation with probiotics with symbiotic may help in the control of hyperglycemia and T2DM, larger studies are needed to confirm. The glucose-lowering effect is due to the metabolites of these bacteria which was shown to affect biological signaling pathways, modulated genes involved in ubiquitination and proteasome process, and altered autonomic nerve activity [1]. It is also vital to note that probiotics or synbiotic alone did not cause a significant reduction in fasting blood glucose levels.

#### **3.3. Hypercholesterolemia**

An example of this is the serum amyloid A3 protein where the expression in adipose tissue is regulated by gut microbiota [7]. Any alteration to the gut microbiota could then also potentially play a role in body weight due to intestinal microbiota effects on adiposity and the regulation

Having diabetes or having the risk of diabetes is often associated with a higher risk for cardiovascular disease. This is because of a compensatory action resulting in hyperinsulinemia which leads to a variety of metabolic abnormalities. Individuals who have diabetes were found to have altered intestinal microbiota which can cause increased adiposity, B-cell dysfunction, metabolic endotoxemia, systemic inflammation, and oxidative stress related to their disease. SCFA is an important function in type 2 diabetes mellitus (T2DM); however, bacteria producing SCFA numbers are lower in diabetic individual [7]. Probiotics may offer a benefi-

Oral supplements, which contained viable and freeze-dried stains, were found to reduce fasting plasma glucose when compared to a placebo group. Fermented food was also noted to not only aid in the prevention of diabetes but also cause favorable changes in those already diagnosed with diabetes [6]. This could be due to some probiotics delaying the glucose intolerance and hyperglycemia state in individuals. For those with diabetes, some probiotics in fermented food decrease insulin requirements and could increase insulin sensitivity for non-

Diabetes has a connection to long-term inflammation. This is due to the consumption of high fats and high fructose which causes chronic inflammation leading to the induction of insulin resistance (IR) and disruption of gut flora. This is supported by studies, which have found that certain diets, for example, high-fat diets, tend to increase lipopolysaccharide (LPS) contained in gut microbiota which leads to a decrease of *Bifidobacteria*. This leads to an inflammation state which may be associated to insulin resistance and weight gain [1]. Different probiotics have differential immune pro- or anti-inflammatory action through the attenuation of nuclear factor kappa B (NF-kB) [4]. *Lactobacillus* is a lactic acid bacteria that contains immune stimulating properties [28]. Probiotics, *L. reuteri,* and *L. plantarum* have anti-inflammatory and antioxidant effects which can aid in the management of diabetes [9]. For example, C-reactive protein (CRP), an inflammation marker, is noted to decrease when these probiotic supplements are used [13]. In a meta-analysis, there was no statistically significant glucose-lowering effect of probiotics when combined with prebiotics [1]. However, prebiotics may affect the inflammation state due to prebiotics having immunomodulatory benefits. In a study, prebiotics were found to alleviate chronic inflammation, which could lower the risk of development of cardiovascular disease and diabetes [2]. Probiotics may even possibly assist in the prevention of diabetes through bacterial translocation to mesenteric adipose tissue. This is mediated through acetate

Hyperglycemia, which is a property of diabetes, is a term given when a person has continuous high-fasting blood glucose (>6.1) and is associated with different diseases, the main one being

cial therapy for diabetic patients through increasing SCFA and other methods.

production and an increase in gut epithelial integrity [26].

of fat storages.

56 Probiotics - Current Knowledge and Future Prospects

**3.2. Diabetes**

diabetics [6].

Cardiovascular disease, affecting both blood vessels and/or heart, usually is the result of hypercholesterolemia and dyslipidemia. There have not been direct studies that compare the effect of prebiotic intake on cardiovascular health; however, there has been an observation on the serum lipid profiles, which all have an effect on CV [2]. These experiments have observed the effect of probiotics and/or prebiotics both in vitro and in vivo on lowering cholesterol [7]. In order to use probiotics to help lower cholesterol, the probiotics adhesion property to the human intestinal epithelial cells is a critical characteristic that must be considered [14]. This characteristic is to ensure that there is extended probiotic transit time in the gastrointestinal trace which was found to cause cholesterol-lowering effects in vivo.

Studies have shown a lower low-density lipoprotein and total cholesterol, along with increases in high-density lipoprotein cholesterol, a reduction in systolic blood pressure (SBP), increases in antioxidant activity, and influences on leptin regulation as a result of probiotics [9]. This is done through an enzyme called bile salt hydrolase (BSH) which causes a decrease in the absorption of cholesterol in the blood stream and is an essential criterion for the selection of probacteria [9, 13]. This enzyme unconjugated bile acids, which eventually cause a decrease in circulating triglycerides and plasma LDL and VLDL levels [12, 20]. The most associated BSH active probiotics are *Lactobacillus*, *Lactococcus,* and *Bifidobacterium* [21]. These bacteria have been observed to lower cholesterol both in vitro and in vivo [28].

For example, see [14], which found that *L. fermentum* NCIMB 5221 and NCIMB 2797 were able to lower cholesterol in an in vitro analysis. They found that *L. plantarum* ATC 14917 had the best results [22]. Another study found that the BSH candidate *L. reuteri* NCIMB 30242 had the capabilities to lower cholesterol in otherwise healthy individuals [12]. This is because *Lactobacillus* species are able to colonize and survive in small intestines [21]. These studies have demonstrated why lactic acid bacteria with BSH are being classified as having hypocholesterol effect. More specifically, trials that used multiple strains versus single strains and fermented products versus capsule found that multi-strain and fermented methods both caused a decrease in total cholesterol and LDL [13].

sodium sensitivity, personal habits, anxiety, and stress. While dietary strategies have been the focus of target for repairing the disturbed gut microbiota, probiotics have been found to decrease systolic/diastolic pressures (approximately 14–6.9 mm drop) in prehypertensive and hypertensive patients. This blood pressure (BP)-lowering effect through probiotics is due to a decrease in nitrogen oxide production in macrophages, reducing reactive oxygen species and enhancing dietary calcium absorption using different mechanism. These mechanisms have been found to be related to the production of SCFAs, CLA, GA A, and angiotensin-converting enzyme (ACE) inhibitor peptides [8]. Short-chain fatty acids (SCFAs), which have a role in both energy metabolism and adipose tissue expansion, also have two sensory receptors that have been linked to BP regulation. Some of the probiotic strains that were noted to cause a decrease in SBP were *L. casei*, *Streptococcus thermophiles*, *L. plantarum*, and *L. helveticus* [9]. Fermented milk products have been shown to have antihypertensive properties in both animal models and clinical trials [6]. Blood pressure release may also be due to a decrease in

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On continuing, blood pressure is normally controlled with a variety of biochemical pathways, including the RAS system. The generation of antihypertensive bioactive peptides causes an ACE-inhibitory activity [8]. Different strains of probiotics have varying potencies as ACE inhibitory activity based on different bioactive peptides [18]. When prebiotics were used along with probiotics or the probiotic strains were enhanced via fermentation substrates, the proteolytic activity and ACE inhibition were increased [20]. Fermentation is able to produce bioactive ACE-inhibitory type peptides, casokinins and lactokinins. Probiotics are able to generate these peptides though fermentation having caseinolytic and lactose hydrolyzing enzyme systems [9]. Consuming probiotic soy milk led to a decrease in BP in a limited number of type II diabetic mellitus subject in a clinical trial lasting 8 weeks [15]. This study did not find any alterations of anthropometric measures which had been found in other studies. This could be that there are strain-specific properties [15]. However, subpopulation studies showed no significant difference and there are no definitive recommendations at this time.

Cardio-arterial diseases are often associated with hypercholesterolemia, diabetes, and other metabolic-related diseases. Alteration to the gut microbiota can cause a detrimental risk of obtaining a cardio-arterial disease/state such as atherosclerosis. The change in gut microbiota can cause an increase in the level of trimethylamine N-oxide (TMAO), which has been linked to an increased risk of major adverse cardiovascular events observed in large clinical cohorts. However, additional studies are needed to determine the mechanism of CVD through

Apo A-V deficient mice were found to have increased precursors of small dense LDL, which is a predictor of coronary artery disease [16]. This deficiency has been observed with bile salt hydrolase expressing probiotics to have an important role in not only lipid metabolism but also atherosclerosis development. *L. reuteri* NCIMB 30242 when provided to non-diabetic subjects with hypertriglyceridemia caused a decrease in apolipoprotein B, which is associated with atherogenic VLDL and LDL products [16]. It was also shown to reduce CRP and fibrinogen which are two factors of atherogenesis [12]. However, this study only included small healthy

blood lipids, body weight, and IR.

**3.5. CAD**

TMAO [7].

Probiotic soy products in association with cardiovascular risk factors were observed. The fecal microbiota that was used was *Lactobacillus* spp., *Bifidobacterium* spp., *Enterococcus* spp., *Enterobacteriaceae*, and *Clostridium* spp. populations. Their results showed a negative correlation with *Enterococcus* spp., *Lactobacillus* spp., and *Bifidobacterium* spp. with cholesterol, non-HDL cholesterol, and autoantibody against LDL [29]. However, this study was performed with rabbits, and future studies with human subjects are necessary for a confirmed effect.

High-density cholesterol, HDL, is considered good cholesterol and is important for removing "bad" cholesterol from the blood stream. This study found that there was a positive correlation between *Lactobacillus*, *Bifidobacterium*, *Enterococcus,* and HDL-C levels [29]. However, in relation to T2DM patients, there were some studies, which found that probiotics failed to maintain a significant effect on lipid profiles [7]. Prebiotics, however, were found to maintain hypocholesterolemic effects in the T2DM individuals [7].

Other methods in which probiotics affect blood lipids include binding and incorporating cholesterol to their cell membrane, which decreases the amount of intestinal cholesterol available for absorption, and by producing SCFA which inhibit hydroxymethylglutaryl CoA reductase. *Lactobacillus* species have protease-sensitive receptors on their cell surface. These receptors bind to exogenous cholesterol or phosphatidylcholine vessels, which then incorporate cholesterol into their cell membrane. This is strain- and growth-dependent action [21].

Probiotics, performing the mechanism of a 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase inhibitor, was shown with dietary fibers (prebiotics) altering the functionality of gut microbiome including the stimulation of microbial metabolite production such as shortchain fatty acid which impacts cholesterol metabolism. The lowering of cholesterol with prebiotics is believed to occur through two mechanisms. The first one is it lowers cholesterol absorption by enhancing cholesterol excretion via feces and the second is through the production of SCFAs upon selective fermentation by intestinal bacterial microflora. Inulin and arabinoxylan, both prebiotics, can alter gut microbiome to stimulate SCFA production which has been already shown to effect cholesterol metabolism [12]. The mechanism behind this is that cholesterol is removed though the incorporation of cholesterol into cellular membranes in the intestine [13].

In terms of fermented food, *Monascus purpureus* rice was found have similar actions as statin and acted as a HMG-CoA reductase inhibitor, decreasing the makeup of cholesterol [6]. The studies that have conflicting findings could possibly be due to the delivery system. Studies varied whether the probiotics were given in capsule versus fermented foods. However, in a limited number of meta-analysis of studies, it was found that probiotics using fermented foods were more effective in reducing total cholesterol and LDL than in capsule [13]. In the majority of studies that were reviewed, there was no control for individual's lifestyles in human subjects which could alter the findings.

#### **3.4. Hypertension**

Hypertension has several risk factors, such as sedentary lifestyle, lipid and hypercholesterolemia, chronic inflammation, inconsistent modulation of renin-angiotensin system (RAS), sodium sensitivity, personal habits, anxiety, and stress. While dietary strategies have been the focus of target for repairing the disturbed gut microbiota, probiotics have been found to decrease systolic/diastolic pressures (approximately 14–6.9 mm drop) in prehypertensive and hypertensive patients. This blood pressure (BP)-lowering effect through probiotics is due to a decrease in nitrogen oxide production in macrophages, reducing reactive oxygen species and enhancing dietary calcium absorption using different mechanism. These mechanisms have been found to be related to the production of SCFAs, CLA, GA A, and angiotensin-converting enzyme (ACE) inhibitor peptides [8]. Short-chain fatty acids (SCFAs), which have a role in both energy metabolism and adipose tissue expansion, also have two sensory receptors that have been linked to BP regulation. Some of the probiotic strains that were noted to cause a decrease in SBP were *L. casei*, *Streptococcus thermophiles*, *L. plantarum*, and *L. helveticus* [9]. Fermented milk products have been shown to have antihypertensive properties in both animal models and clinical trials [6]. Blood pressure release may also be due to a decrease in blood lipids, body weight, and IR.

On continuing, blood pressure is normally controlled with a variety of biochemical pathways, including the RAS system. The generation of antihypertensive bioactive peptides causes an ACE-inhibitory activity [8]. Different strains of probiotics have varying potencies as ACE inhibitory activity based on different bioactive peptides [18]. When prebiotics were used along with probiotics or the probiotic strains were enhanced via fermentation substrates, the proteolytic activity and ACE inhibition were increased [20]. Fermentation is able to produce bioactive ACE-inhibitory type peptides, casokinins and lactokinins. Probiotics are able to generate these peptides though fermentation having caseinolytic and lactose hydrolyzing enzyme systems [9]. Consuming probiotic soy milk led to a decrease in BP in a limited number of type II diabetic mellitus subject in a clinical trial lasting 8 weeks [15]. This study did not find any alterations of anthropometric measures which had been found in other studies. This could be that there are strain-specific properties [15]. However, subpopulation studies showed no significant difference and there are no definitive recommendations at this time.

#### **3.5. CAD**

versus capsule found that multi-strain and fermented methods both caused a decrease in total

Probiotic soy products in association with cardiovascular risk factors were observed. The fecal microbiota that was used was *Lactobacillus* spp., *Bifidobacterium* spp., *Enterococcus* spp., *Enterobacteriaceae*, and *Clostridium* spp. populations. Their results showed a negative correlation with *Enterococcus* spp., *Lactobacillus* spp., and *Bifidobacterium* spp. with cholesterol, non-HDL cholesterol, and autoantibody against LDL [29]. However, this study was performed with rabbits, and future studies with human subjects are necessary for a confirmed effect.

High-density cholesterol, HDL, is considered good cholesterol and is important for removing "bad" cholesterol from the blood stream. This study found that there was a positive correlation between *Lactobacillus*, *Bifidobacterium*, *Enterococcus,* and HDL-C levels [29]. However, in relation to T2DM patients, there were some studies, which found that probiotics failed to maintain a significant effect on lipid profiles [7]. Prebiotics, however, were found to maintain

Other methods in which probiotics affect blood lipids include binding and incorporating cholesterol to their cell membrane, which decreases the amount of intestinal cholesterol available for absorption, and by producing SCFA which inhibit hydroxymethylglutaryl CoA reductase. *Lactobacillus* species have protease-sensitive receptors on their cell surface. These receptors bind to exogenous cholesterol or phosphatidylcholine vessels, which then incorporate choles-

Probiotics, performing the mechanism of a 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase inhibitor, was shown with dietary fibers (prebiotics) altering the functionality of gut microbiome including the stimulation of microbial metabolite production such as shortchain fatty acid which impacts cholesterol metabolism. The lowering of cholesterol with prebiotics is believed to occur through two mechanisms. The first one is it lowers cholesterol absorption by enhancing cholesterol excretion via feces and the second is through the production of SCFAs upon selective fermentation by intestinal bacterial microflora. Inulin and arabinoxylan, both prebiotics, can alter gut microbiome to stimulate SCFA production which has been already shown to effect cholesterol metabolism [12]. The mechanism behind this is that cholesterol is removed

terol into their cell membrane. This is strain- and growth-dependent action [21].

though the incorporation of cholesterol into cellular membranes in the intestine [13].

In terms of fermented food, *Monascus purpureus* rice was found have similar actions as statin and acted as a HMG-CoA reductase inhibitor, decreasing the makeup of cholesterol [6]. The studies that have conflicting findings could possibly be due to the delivery system. Studies varied whether the probiotics were given in capsule versus fermented foods. However, in a limited number of meta-analysis of studies, it was found that probiotics using fermented foods were more effective in reducing total cholesterol and LDL than in capsule [13]. In the majority of studies that were reviewed, there was no control for individual's lifestyles in

Hypertension has several risk factors, such as sedentary lifestyle, lipid and hypercholesterolemia, chronic inflammation, inconsistent modulation of renin-angiotensin system (RAS),

hypocholesterolemic effects in the T2DM individuals [7].

human subjects which could alter the findings.

**3.4. Hypertension**

cholesterol and LDL [13].

58 Probiotics - Current Knowledge and Future Prospects

Cardio-arterial diseases are often associated with hypercholesterolemia, diabetes, and other metabolic-related diseases. Alteration to the gut microbiota can cause a detrimental risk of obtaining a cardio-arterial disease/state such as atherosclerosis. The change in gut microbiota can cause an increase in the level of trimethylamine N-oxide (TMAO), which has been linked to an increased risk of major adverse cardiovascular events observed in large clinical cohorts. However, additional studies are needed to determine the mechanism of CVD through TMAO [7].

Apo A-V deficient mice were found to have increased precursors of small dense LDL, which is a predictor of coronary artery disease [16]. This deficiency has been observed with bile salt hydrolase expressing probiotics to have an important role in not only lipid metabolism but also atherosclerosis development. *L. reuteri* NCIMB 30242 when provided to non-diabetic subjects with hypertriglyceridemia caused a decrease in apolipoprotein B, which is associated with atherogenic VLDL and LDL products [16]. It was also shown to reduce CRP and fibrinogen which are two factors of atherogenesis [12]. However, this study only included small healthy hypercholesterolemia population, and the probiotic was given either in capsule or in yoghurt format. In mice, *Lactobacillus* species was found to lower arteriosclerosis [20]. When provided through powered supplement, *L. curvatus* and *L. plantarum* caused a significant increase in apo A-V [16]. With varying methods of providing the probiotics, more controlled studies are necessary to understand the relationship between probiotics and cardio-arterial disease.

individual [9]. From the time an individual is born until his/her death, there will be more than 500 different species of microorganism that are contained in the human body [6, 7]. An individual's microbial diversity changes throughout his/her life span and depends on a person's health-related interaction between gut microbiota and host's overall health [7]. There are even geographic variations that have been found in relation to the type of *Lactobacillus*, varying from the western and eastern hemispheres. The factors that can influence a person's

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The colon has the largest variety of microorganism and is the focus part of most studies [4]. *Bifidobacterium*, *Lactobacillus*, *Propionibacterium*, and *Bacteroidetes* are the dominant species of obligate microflora [5]. Lactic acid-producing *Bifidobacterium* and *Lactobacillus* are often the focal points of studies due to their beneficial effects that is caused by their expression of immunomodulatory and pathogen-antagonistic molecules [2]. These bacteria produce butyrate, which highlights some properties of propionate and is observed as the preferred metabolic fuel for colonocytes possessing antineoplastic properties. This contributes to energy production [4]. Propionate affects colonic muscular contraction, relaxation of resistance vessels, and

There are several ways that a human's microbiota aids overall health; examples of this include endogenous symbiont microorganisms, microbiota, changing not only gene expression but also have an effect on pH, redox balance, and the ratio between pro-inflammatory and antiinflammatory cytokines. There are also studies which showed normal microbiota effect on brain metabolism, the immune system, and a couple of homeostatic routes [3]. There have been several studies that have noted a change of gut microbiota in several conditions/diseases such as obesity, fatty liver, insulin-resistant diabetes mellitus, and hypertension [11]. Some examples of these changes are an increase in *Firmicutes* and a decrease in *Bacteroidetes* [18]. With recent studies showing gut microbiota related to the pathogenesis of cardiovascular disease, probiotics, which are live microbial food supplements, could balance intestinal

microbial resulting in the treatment or prevention of cardiovascular disease [9, 11].

The gut environment also plays a role in the type of bacteria found per location in the tract. The tract varies from an alkaline pH in the small bowel to an acidic pH in the stomach [31, 32]. Using the 16 s ribosomal RNA gene sequence-based metagenomics methods, it has been determined that 90% of bacteria of the gut belong mainly to the *Bacteroidetes* and *Firmicutes* phylum [27]. It has been discovered that both are lactic acid bacteria which are vital to the gastrointestinal track normal residents. These two are commonly used in fermented food for the prevention and treatment of different disorders ranging from constipation to high cholesterol levels [27]. When an individual is healthy, most of the microbiota act symbiotically with the host. The major metabolic function of microbiota is to assist with the harvest of nutrients and energy from different diets that human's consume [4]. The interaction between the gut epithelial cells and the microbes and the metabolites produced is responsible for the maturation of intestinal epithelial cells, enteric nervous system, intestinal vascular system, and the mucosal immune system. However, an imbalance in gut bacteria has been shown in numerous studies to be linked to a variety of diseases. Intestinal disease state can affect the microflora, impair the gut barrier, and/or cause intestinal inflammation which can all lead to imbalance in gut bacteria population

microbiota are genetics, age, diet, and antibiotic use [8].

stimulation of colonic electrolyte transport and insulin resistance [4].

Fermented products may provide a decrease in the development of atherosclerosis with the activation of G-protein-coupled bile acid receptor [25]. In a study that compared atherosclerotic lesions in the aortic vessel in animals treated with fermented soy product supplements versus a control group, the ones that were provided the supplement was found to have a lower percentage of aortic vessel covered with lesions [29]. Fermented whole grains are also able to lower coronary heart disease [6].

#### **3.6. Heart failure**

Heart failure causes a variety of systemic effects on multiple organs. While there are no heart failure changes observed to effect the gut microbial composition, there have been changes that could cause or increase the incidence of heart failures. New research is currently observing probiotics therapy providing direct cardio-protective effect to the heart. This protection would result in a reduced ischemic injury and improve cardiac function after an infarction [20]. TMAO, which is effected by gut microbiota, can be linked to both the development and progression of atherosclerosis and cardiovascular disease and is effected by gut microbiota [21]. However, a majority of studies have only observed the effects in mice. Continuing due to individuals not realizing that they are at risk for infarction, consuming probiotics as prophylaxis is unlikely and the prevalence of heart failure is stagnant.

#### **3.7. Chronic kidney diseases**

Patients with chronic kidney disease have an increased risk for cardiovascular disease through having hyperhomocysteinemia, increased lipoprotein, oxidative stress, and inflammation. Vascular dysfunction in both humans and experimental animals with CKD has been discovered to be due to an increased production and impaired renal excretion of p-cresyl sulfate and indoxyl sulfate which pairs CKD with vascular disease. These toxins along with others are normally cleared by the kidneys. When kidney patients were provided probiotics, there was a decrease in those toxins. However, due to the uremic environment of the gut that is often associated with CKD, probiotic may become ineffective or less ineffective [23].

#### **3.8. Relationship to GI system**

A population of microbes that assist the host's biochemical metabolic and immunological balance necessary for health maintenance is termed normal microbiota [6]. Both composition and function characterize the biodiversity of microbiota [4]. The gastrointestinal microbiota includes bacteria, archaea, protozoa, fungi, and different viruses, with anaerobic bacteria and the predominant source [4]. The numbers range from 10 to 100 trillion microorganisms in the GI tract, which, based on an individual's genetic age and diet, vary from individual to individual [9]. From the time an individual is born until his/her death, there will be more than 500 different species of microorganism that are contained in the human body [6, 7]. An individual's microbial diversity changes throughout his/her life span and depends on a person's health-related interaction between gut microbiota and host's overall health [7]. There are even geographic variations that have been found in relation to the type of *Lactobacillus*, varying from the western and eastern hemispheres. The factors that can influence a person's microbiota are genetics, age, diet, and antibiotic use [8].

hypercholesterolemia population, and the probiotic was given either in capsule or in yoghurt format. In mice, *Lactobacillus* species was found to lower arteriosclerosis [20]. When provided through powered supplement, *L. curvatus* and *L. plantarum* caused a significant increase in apo A-V [16]. With varying methods of providing the probiotics, more controlled studies are necessary to understand the relationship between probiotics and cardio-arterial disease.

Fermented products may provide a decrease in the development of atherosclerosis with the activation of G-protein-coupled bile acid receptor [25]. In a study that compared atherosclerotic lesions in the aortic vessel in animals treated with fermented soy product supplements versus a control group, the ones that were provided the supplement was found to have a lower percentage of aortic vessel covered with lesions [29]. Fermented whole grains are also

Heart failure causes a variety of systemic effects on multiple organs. While there are no heart failure changes observed to effect the gut microbial composition, there have been changes that could cause or increase the incidence of heart failures. New research is currently observing probiotics therapy providing direct cardio-protective effect to the heart. This protection would result in a reduced ischemic injury and improve cardiac function after an infarction [20]. TMAO, which is effected by gut microbiota, can be linked to both the development and progression of atherosclerosis and cardiovascular disease and is effected by gut microbiota [21]. However, a majority of studies have only observed the effects in mice. Continuing due to individuals not realizing that they are at risk for infarction, consuming probiotics as prophy-

Patients with chronic kidney disease have an increased risk for cardiovascular disease through having hyperhomocysteinemia, increased lipoprotein, oxidative stress, and inflammation. Vascular dysfunction in both humans and experimental animals with CKD has been discovered to be due to an increased production and impaired renal excretion of p-cresyl sulfate and indoxyl sulfate which pairs CKD with vascular disease. These toxins along with others are normally cleared by the kidneys. When kidney patients were provided probiotics, there was a decrease in those toxins. However, due to the uremic environment of the gut that is often

A population of microbes that assist the host's biochemical metabolic and immunological balance necessary for health maintenance is termed normal microbiota [6]. Both composition and function characterize the biodiversity of microbiota [4]. The gastrointestinal microbiota includes bacteria, archaea, protozoa, fungi, and different viruses, with anaerobic bacteria and the predominant source [4]. The numbers range from 10 to 100 trillion microorganisms in the GI tract, which, based on an individual's genetic age and diet, vary from individual to

associated with CKD, probiotic may become ineffective or less ineffective [23].

able to lower coronary heart disease [6].

60 Probiotics - Current Knowledge and Future Prospects

laxis is unlikely and the prevalence of heart failure is stagnant.

**3.6. Heart failure**

**3.7. Chronic kidney diseases**

**3.8. Relationship to GI system**

The colon has the largest variety of microorganism and is the focus part of most studies [4]. *Bifidobacterium*, *Lactobacillus*, *Propionibacterium*, and *Bacteroidetes* are the dominant species of obligate microflora [5]. Lactic acid-producing *Bifidobacterium* and *Lactobacillus* are often the focal points of studies due to their beneficial effects that is caused by their expression of immunomodulatory and pathogen-antagonistic molecules [2]. These bacteria produce butyrate, which highlights some properties of propionate and is observed as the preferred metabolic fuel for colonocytes possessing antineoplastic properties. This contributes to energy production [4]. Propionate affects colonic muscular contraction, relaxation of resistance vessels, and stimulation of colonic electrolyte transport and insulin resistance [4].

There are several ways that a human's microbiota aids overall health; examples of this include endogenous symbiont microorganisms, microbiota, changing not only gene expression but also have an effect on pH, redox balance, and the ratio between pro-inflammatory and antiinflammatory cytokines. There are also studies which showed normal microbiota effect on brain metabolism, the immune system, and a couple of homeostatic routes [3]. There have been several studies that have noted a change of gut microbiota in several conditions/diseases such as obesity, fatty liver, insulin-resistant diabetes mellitus, and hypertension [11]. Some examples of these changes are an increase in *Firmicutes* and a decrease in *Bacteroidetes* [18]. With recent studies showing gut microbiota related to the pathogenesis of cardiovascular disease, probiotics, which are live microbial food supplements, could balance intestinal microbial resulting in the treatment or prevention of cardiovascular disease [9, 11].

The gut environment also plays a role in the type of bacteria found per location in the tract. The tract varies from an alkaline pH in the small bowel to an acidic pH in the stomach [31, 32]. Using the 16 s ribosomal RNA gene sequence-based metagenomics methods, it has been determined that 90% of bacteria of the gut belong mainly to the *Bacteroidetes* and *Firmicutes* phylum [27]. It has been discovered that both are lactic acid bacteria which are vital to the gastrointestinal track normal residents. These two are commonly used in fermented food for the prevention and treatment of different disorders ranging from constipation to high cholesterol levels [27].

When an individual is healthy, most of the microbiota act symbiotically with the host. The major metabolic function of microbiota is to assist with the harvest of nutrients and energy from different diets that human's consume [4]. The interaction between the gut epithelial cells and the microbes and the metabolites produced is responsible for the maturation of intestinal epithelial cells, enteric nervous system, intestinal vascular system, and the mucosal immune system. However, an imbalance in gut bacteria has been shown in numerous studies to be linked to a variety of diseases. Intestinal disease state can affect the microflora, impair the gut barrier, and/or cause intestinal inflammation which can all lead to imbalance in gut bacteria population [31]. In order to reestablish a balance, probiotics, prebiotics, and synbiotics have been used and observed. Probiotics are able to affect the GI tract through their interaction with the intestinal epithelial cells, luminal flora, and mucosal immune cell components of the GI tract [28].

or pathogenic organisms. It is vital to know that these microbes' preference to coproduce certain fermentation products depend on the prebiotic structures and the bacterial communities [2]. Example of acidic fermentation products are lactate and short-chain fatty acid, butyrate acetate, and propionate [2]. These products can have benefits in the gut, for example, butyrate supports intestinal epithelium, and along with other SCFAs, they have benefits

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Before recommendations on probiotics are made, the following are needed to be taken into account: an individual's immunity, genetics, and diet [9]. The type of probiotics being suggested may differ based on goals and shelf life. World Health Organization (WHO) suggests that in order to provide health benefits, probiotics must be able to endure human digestion including gastric juices and bile and be capable of multiplying once they arrive in the GI tract [9]. The focus should be on the origin of the strain, its colonizing ability, and its safety and efficacy [4]. The amount varies based on the goal; however, it must be adequate enough to have colonization and effect [30]. The duration of the effect varies from probiotics. Studies

There are an increasing number of probiotic products made available to consumers which include yogurt, other fermented milk and food products as well as various forms of dietary supplements [9]. Individual preferences can vary on the method of ingestion of probiotics. These are usually prepared using lactic acid bacteria of four general species, *Lactobacillus*, and *Bifidobacterium*. Probiotics are used in a variety of food sources not only in traditionally fermented food but are now being added to meat products, snacks, fruits, and juices [5]. Functional properties that lead to microorganisms in fermented foods have probiotics properties, antimicrobial properties, fibrolytic activity, and degradation of antinutritive compounds which may be essential when looking into the selection of a starter culture to be used in the

In terms of prebiotics, foods such as artichoke, asparagus, garlic, and wheat have a variety of compound types that have been looked at for prebiotic attributes such as various length oligosaccharides and galacto-oligosaccharides/trans-oligosaccharides [2]. Monosaccharides, di-, and tri- may be used for prebiotics if they have host-indigestible bonds. Other examples of what have been used are sugar alcohol, cycle disaccharide difructose, and hydride II [2]. In order to have a beneficial effect from prebiotics, usually an individual will need 5 g or more to produce enough fermentation [1]. However, to avoid risk related to fermented food, a maxi-

It is vital to recognize that there are no standard guidelines currently existing for oral administration, and the individual use of probiotic and prebiotics should be carefully monitored in order to determine potential adverse reaction [7]. More long-term well-controlled double-

mum limit of 100 mg/kg of histamine indicates safe level for consumption [6].

**4. Current recommendation for its use and types of availability**

have found that most effects only last as long as they are consumed [31].

that are distal to the gut system.

makeup of functional foods [5].

blinded studies are needed.

Antibiotics usage in early life has been determined to deplete some components of microbiota causing disrupted normal gut microbiota development [4]. Prebiotics such as fructooligosaccharides do not support the growth of antibiotic-related pathogens like *C. difficile* [31]. Several studies have observed the efficacy of different probiotic strains in the treatment of antibiotic/*C. difficile*-associated diarrhea. *L. acidophilus*, *L. rhamnosus* GG, *L. delbrueckii*, and *L. fermentum* are several bacteria that have been shown to decrease the occurrence of antibiotic-induced diarrhea [10]. *C. difficile*, a main concern with the usage of antibiotics pathogenesis, is the disruption of indigenous intestinal microbiome. Probiotics were shown in several studies to decrease *C. difficile* risks; those studies had several limitations such as the type of probiotic variation, the duration of use, and different dosages [35]. Therefore, *C. difficile* and probiotic relationship require more in-depth research.

There have been a variety of studies that observe and prove the health benefits and clinical effects of probiotics to GI abnormalities such as irritable bowel syndrome, gastric ulcer, and antibiotic-associated diarrhea and some cancers [8]. *Lactobacillus* and *Bifidobacteria* influence on resident microbiota can range from temporarily replacing missing parts or supplementing certain population, or by stimulating some of the resident microbiota. *Lactobacillus* species, which has been noted in several studies to provide beneficial effects when they are presented, is metabolically active and contains several properties that affect the whole intestinal microbiota biodiversity [4]. Prebiotics have been shown to suppress indigestion and diarrhea that were caused by pathogens [2].

Continuing, they can also aid in preventing the growth of harmful competitors, prevent the growth of exogenous microbes, and lower the substrate availability for pathogens [19]. *L. fermentum* ME-3 has been found able to suppress Gram-negative bacteria. Some probiotics have an antagonistic effect such as *L. paracasei* and *L. plantarum* with *Salmonella* (microaerobic), *L. plantarum* against *C. difficile* colitis (anaerobic), *L. paracasei* against *Helicobacter pylori*, and *B. lactis/B. longum* against *Shigella sonnei* and *E. coli*. Inflammatory bowel disease, which consists mainly of ulcerative colitis and Crohn's disease, has been shown related to intestinal flora dysbiosis through clinical and research studies. In an analysis of several studies, probiotics were determined to have a better outcome than non-probiotics therapy for maintenance therapy. However, they did not give benefit in inducing the remission of ulcerative colitis. This could be due to various methods used, different sample sizes, and controlled variables [34].

Prebiotics can also influence the composition of bacteria in human gut [9]. Several studies showed that when given supplements of fructan and inulin, there was an increased number of *Bifidobacteria* [19]. Other types of prebiotics that have been found to positively affect the gut microbe are arabinoxylan and inulin. These two have a modifying ability through affecting the makeup of and function ability of gut microbe [12]. *Bifidobacteria* and *Lactobacilli* selected fermentation of prebiotics have supported symbiotic gut microbiota through improving numbers of these commensals and decreasing the number of neutral or pathogenic organisms. It is vital to know that these microbes' preference to coproduce certain fermentation products depend on the prebiotic structures and the bacterial communities [2]. Example of acidic fermentation products are lactate and short-chain fatty acid, butyrate acetate, and propionate [2]. These products can have benefits in the gut, for example, butyrate supports intestinal epithelium, and along with other SCFAs, they have benefits that are distal to the gut system.

#### **4. Current recommendation for its use and types of availability**

[31]. In order to reestablish a balance, probiotics, prebiotics, and synbiotics have been used and observed. Probiotics are able to affect the GI tract through their interaction with the intestinal

Antibiotics usage in early life has been determined to deplete some components of microbiota causing disrupted normal gut microbiota development [4]. Prebiotics such as fructooligosaccharides do not support the growth of antibiotic-related pathogens like *C. difficile* [31]. Several studies have observed the efficacy of different probiotic strains in the treatment of antibiotic/*C. difficile*-associated diarrhea. *L. acidophilus*, *L. rhamnosus* GG, *L. delbrueckii*, and *L. fermentum* are several bacteria that have been shown to decrease the occurrence of antibiotic-induced diarrhea [10]. *C. difficile*, a main concern with the usage of antibiotics pathogenesis, is the disruption of indigenous intestinal microbiome. Probiotics were shown in several studies to decrease *C. difficile* risks; those studies had several limitations such as the type of probiotic variation, the duration of use, and different dosages [35]. Therefore, *C. difficile* and

There have been a variety of studies that observe and prove the health benefits and clinical effects of probiotics to GI abnormalities such as irritable bowel syndrome, gastric ulcer, and antibiotic-associated diarrhea and some cancers [8]. *Lactobacillus* and *Bifidobacteria* influence on resident microbiota can range from temporarily replacing missing parts or supplementing certain population, or by stimulating some of the resident microbiota. *Lactobacillus* species, which has been noted in several studies to provide beneficial effects when they are presented, is metabolically active and contains several properties that affect the whole intestinal microbiota biodiversity [4]. Prebiotics have been shown to suppress indigestion and diarrhea that

Continuing, they can also aid in preventing the growth of harmful competitors, prevent the growth of exogenous microbes, and lower the substrate availability for pathogens [19]. *L. fermentum* ME-3 has been found able to suppress Gram-negative bacteria. Some probiotics have an antagonistic effect such as *L. paracasei* and *L. plantarum* with *Salmonella* (microaerobic), *L. plantarum* against *C. difficile* colitis (anaerobic), *L. paracasei* against *Helicobacter pylori*, and *B. lactis/B. longum* against *Shigella sonnei* and *E. coli*. Inflammatory bowel disease, which consists mainly of ulcerative colitis and Crohn's disease, has been shown related to intestinal flora dysbiosis through clinical and research studies. In an analysis of several studies, probiotics were determined to have a better outcome than non-probiotics therapy for maintenance therapy. However, they did not give benefit in inducing the remission of ulcerative colitis. This could be

due to various methods used, different sample sizes, and controlled variables [34].

Prebiotics can also influence the composition of bacteria in human gut [9]. Several studies showed that when given supplements of fructan and inulin, there was an increased number of *Bifidobacteria* [19]. Other types of prebiotics that have been found to positively affect the gut microbe are arabinoxylan and inulin. These two have a modifying ability through affecting the makeup of and function ability of gut microbe [12]. *Bifidobacteria* and *Lactobacilli* selected fermentation of prebiotics have supported symbiotic gut microbiota through improving numbers of these commensals and decreasing the number of neutral

epithelial cells, luminal flora, and mucosal immune cell components of the GI tract [28].

probiotic relationship require more in-depth research.

62 Probiotics - Current Knowledge and Future Prospects

were caused by pathogens [2].

Before recommendations on probiotics are made, the following are needed to be taken into account: an individual's immunity, genetics, and diet [9]. The type of probiotics being suggested may differ based on goals and shelf life. World Health Organization (WHO) suggests that in order to provide health benefits, probiotics must be able to endure human digestion including gastric juices and bile and be capable of multiplying once they arrive in the GI tract [9]. The focus should be on the origin of the strain, its colonizing ability, and its safety and efficacy [4]. The amount varies based on the goal; however, it must be adequate enough to have colonization and effect [30]. The duration of the effect varies from probiotics. Studies have found that most effects only last as long as they are consumed [31].

There are an increasing number of probiotic products made available to consumers which include yogurt, other fermented milk and food products as well as various forms of dietary supplements [9]. Individual preferences can vary on the method of ingestion of probiotics. These are usually prepared using lactic acid bacteria of four general species, *Lactobacillus*, and *Bifidobacterium*. Probiotics are used in a variety of food sources not only in traditionally fermented food but are now being added to meat products, snacks, fruits, and juices [5]. Functional properties that lead to microorganisms in fermented foods have probiotics properties, antimicrobial properties, fibrolytic activity, and degradation of antinutritive compounds which may be essential when looking into the selection of a starter culture to be used in the makeup of functional foods [5].

In terms of prebiotics, foods such as artichoke, asparagus, garlic, and wheat have a variety of compound types that have been looked at for prebiotic attributes such as various length oligosaccharides and galacto-oligosaccharides/trans-oligosaccharides [2]. Monosaccharides, di-, and tri- may be used for prebiotics if they have host-indigestible bonds. Other examples of what have been used are sugar alcohol, cycle disaccharide difructose, and hydride II [2]. In order to have a beneficial effect from prebiotics, usually an individual will need 5 g or more to produce enough fermentation [1]. However, to avoid risk related to fermented food, a maximum limit of 100 mg/kg of histamine indicates safe level for consumption [6].

It is vital to recognize that there are no standard guidelines currently existing for oral administration, and the individual use of probiotic and prebiotics should be carefully monitored in order to determine potential adverse reaction [7]. More long-term well-controlled doubleblinded studies are needed.

#### **5. Summary**

Gut microbial is essential for the balance of pathogens and the control of disease not only at the gastrointestinal tract but also distal to the tract as well. Metabolism and energy balance are major components of cardio-metabolic health [24]. Disease state has been determined to be one cause of an alteration to gut microbial that can affect the stated components. This was observed through different types of microbial environments in patients who are obese or diabetic. This change in gut microbial increases the disease state through the support of its pathogenesis.

Each single strain of multiple strains must be observed individually. This is in order to directly compare the effectiveness of individual strain versus multi-strain [1]. Also, a synergistic effect in the bioactivity of probiotics could result in multi-strain, which can lead to a mutual inhibition by a component strain. This could possibly decrease probiotic efficacy [1]. While there are several probiotics that are available, only some have been shown to be effective and able to colonize [30].

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65

[1] Nikbakht E, Khalesi S, Singh I, Williams L, West N, Colson N. Effect of probiotics and synbiotics on blood glucose: a systematic review and meta-analysis of controlled trials.

[3] Pessione E, Cirrincione S. Bioactive Molecules Released in Food by Lactic Acid Bacteria:

[4] Mikelsaar M, Sepp E, Štšepetova J, Songisepp E, Mändar R. Biodiversity of Intestinal Lactic Acid Bacteria in the Healthy Population. Adv. Exp. Med. Biol. 2016:1-64

[5] Tamang J, Shin D, Jung S, Chae S. Functional Properties of Microorganisms in Fermented

[6] Kobyliak N, Virchenko O, Falalyeyeva T. Pathophysiological role of host microbiota in

[7] Yoo J, Kim S. Probiotics and Prebiotics: Present Status and Future Perspectives on

[8] Sudha R, Upadrasta A. Probiotics and blood pressure: current insights. Integrated Blood

[9] Thushara R, Gangadaran S, Solati Z, Moghadasian M. Cardiovascular benefits of probiotics: a review of experimental and clinical studies. Food & Function. 2016;**7**(2):632-642

[10] Pandey K, Naik S, Vakil B. Probiotics, prebiotics and synbiotics- a review. Journal of

[2] Collins S, Reid G. Distant Site Effects of Ingested Prebiotics. Nutrients. 2016;**8**(9):523

Encrypted Peptides and Biogenic Amines. Frontiers in Microbiology. 2016;**7**

**Author details**

**References**

Suresh Antony\* and Marlina Ponce de Leon

European Journal of Nutrition. 2016

Foods. Frontiers in Microbiology. 2016;**7**

Metabolic Disorders. Nutrients. 2016;**8**(3):173

Food Science and Technology. 2015;**52**(12):7577-7587

Pressure Control. 2016:33

the development of obesity. Nutrition Journal. 2015;**15**(1)

\*Address all correspondence to: suresh.antony@att.net

Burrell College of Osteopathic Medicine, Las Cruces, New Mexico

Dietary supplements, including probiotics, could lower the risk of diseases such as CVD [17]. Probiotics have been known to cause a positive alteration in the gut microbial. They are often provided with prebiotics in fermented food and are termed synbiotic. Several studies have observed probiotics, its effect on gut microbial, and its relationship to cardiovascular diseases and risks. Probiotics may offer an alternative treatment for diabetes, obesity, hypercholesterolemia, hypertension, CKD, cardiomyopathy, atherosclerosis (**Table 1**). In order for a better understanding on how probiotics can lower the risks for diseases and treat, more studies need to be performed.


**Table 1.** Main probiotic effect on cardiovascular disease risk-related states.

Each single strain of multiple strains must be observed individually. This is in order to directly compare the effectiveness of individual strain versus multi-strain [1]. Also, a synergistic effect in the bioactivity of probiotics could result in multi-strain, which can lead to a mutual inhibition by a component strain. This could possibly decrease probiotic efficacy [1]. While there are several probiotics that are available, only some have been shown to be effective and able to colonize [30].

#### **Author details**

**5. Summary**

64 Probiotics - Current Knowledge and Future Prospects

pathogenesis.

to be performed.

Diabetes *L. acidophilus***,** *L. rhamnosus* **and** *B. bifidum*

**Bb12**

w. *B. longum*

w/*Streptococcus thermophiles*

**Table 1.** Main probiotic effect on cardiovascular disease risk-related states.

Cholesterol *L. acidophilus*

Hypertension *L. casei*

*L. acidophilus* **and**  *Bifidobacterium lactis*

Gut microbial is essential for the balance of pathogens and the control of disease not only at the gastrointestinal tract but also distal to the tract as well. Metabolism and energy balance are major components of cardio-metabolic health [24]. Disease state has been determined to be one cause of an alteration to gut microbial that can affect the stated components. This was observed through different types of microbial environments in patients who are obese or diabetic. This change in gut microbial increases the disease state through the support of its

Dietary supplements, including probiotics, could lower the risk of diseases such as CVD [17]. Probiotics have been known to cause a positive alteration in the gut microbial. They are often provided with prebiotics in fermented food and are termed synbiotic. Several studies have observed probiotics, its effect on gut microbial, and its relationship to cardiovascular diseases and risks. Probiotics may offer an alternative treatment for diabetes, obesity, hypercholesterolemia, hypertension, CKD, cardiomyopathy, atherosclerosis (**Table 1**). In order for a better understanding on how probiotics can lower the risks for diseases and treat, more studies need

**Microorganism Results Authors**

higher than that in women in placebo group

Significantly lowered fasting blood glucose hemoglobin A1c and malondialdehyde and increased erythrocyte superoxide dismutase and glutathione peroxidase activities and total

Elevation of HDL cholesterol level by 0.3 mmol L-1 and reduction in the ratio of LDL/

8.92%, total cholesterol 4.81%, non-HDL

Systolic pressure lowered significantly (p < 0.05) Kawase et al.

HDL cholesterol from 3.24 to 2.38

A-V levels and LDL particles size

Decline in blood glucose levels by 38% in T2DM

Sanchez et al. [38]

Moroti et al. [39]

Ejtahed et al. [37]

Kiessling et al.

Jones et al. [40]

Ahn et al. [16]

[42]

[36]

Obesity *Lactobacillus rhamosus* Mean weight loss in women was significantly

(p = 0.02)

subjects

antioxidant states

*L. reuteri* A significant reduction in LDL cholesterol

cholesterol 6.01%

*L. curvatus* **and** *L. plantarum* An increase of 21.1 and 15.6% in plasma apo

Suresh Antony\* and Marlina Ponce de Leon

\*Address all correspondence to: suresh.antony@att.net

Burrell College of Osteopathic Medicine, Las Cruces, New Mexico

#### **References**


[11] Nagatomo Y, Tang W. Intersections Between Microbiome and Heart Failure: Revisiting the Gut Hypothesis. Journal of Cardiac Failure. 2015;**21**(12):973-980

[25] DiRienzo D. Effect of probiotics on biomarkers of cardiovascular disease: implications

Probiotics and Its Relationship with the Cardiovascular System

http://dx.doi.org/10.5772/intechopen.75077

67

[26] Carvalho B, Abdalla Saad M. Influence of Gut Microbiota on Subclinical Inflammation

[27] Vyas U, Ranganathan N. Probiotics, Prebiotics, and Synbiotics: Gut and Beyond.

[28] Kumari A, Catanzaro R, Marotta F. Clinical importance of lactic acid bacteria: a short

[29] Cavallini D, Suzuki J, Abdalla D, Vendramini R, Pauly-Silveira N, Roselino M, et al. Influence of a probiotic soy product on fecal microbiota and its association with cardiovascular risk factors in an animal model. Lipids in Health and Disease. 2011;**10**(1):126

[30] Flock MH, Madsen KK, Jenkins DJ, Gandalini S, Katz JA, Onderdonk, A, Walker WA, Fedorak RN, Camilleri M. Recommendations for probiotic use. Journal of Clinical

[32] Dunne C. Adaptation of Bacteria to the Intestinal Niche: Probiotics and Gut Disorder.

[33] Antony S, Stratton C, Dummer J. Lactobacillus Bacteremia: Description of the Clinical Course in Adult Patients Without Endocarditis. Clinical Infectious Diseases. 1996;**23**(4):

[34] Sang L. Remission induction and maintenance effect of probiotics on ulcerative colitis: A

[35] Cooper C, Jump R, Chopra T. Prevention of Infection Due to Clostridium difficile. *Infectious Disease Clinics Of North America* [serial online]. December 1, 2016;**30** (Infection Prevention and Control in Healthcare, Part II: Epidemiology and Prevention of Infections):999-1012. Available from: ScienceDirect, Ipswich. MA. Accessed November

[36] Kawase M, Hashimoto H, Hosoda M, Morita H, Hosono A. Effect of Administration of Fermented Milk Containing Whey Protein Concentrate to Rats and Healthy Men on

[37] Ejtahed H, Mohtadi-Nia J, Homayouni-Rad A, Niafar M, Asghari-Jafarabadi M, Mofid V, et al. Effect of probiotic yogurt containing Lactobacillus acidophilus and Bifidobacterium lactis on lipid profile in individuals with type 2 diabetes mellitus. Journal of Dairy

[38] Sanchez M, Darimont C, Drapeau V, Emady-Azar S, Lepage M, Rezzonico E, et al. Effect of Lactobacillus rhamnosus CGMCC1.3724 supplementation on weight loss and maintenance in obese men and women. British Journal of Nutrition. 2013;**111**(08):1507-1519

Serum Lipids and Blood Pressure. Journal of Dairy Science. 2000;**83**(2):255-263

meta-analysis. World Journal of Gastroenterology. 2010;**16**(15):1908

[31] Probiotics YPK. prebiotics for bowel health. Geriatric Nursing. 2003;**24**(3):192-193

for heart-healthy diets. Nutrition Reviews. 2013;**72**(1):18-29

Gastroenterology Research and Practice. 2012;**2012**:1-16

review. Acta Bio-Medica. 2011;**82**(3):177-180

Gastroenterology. 2006;**40**(3):275-278

773-778

8, 2017

Science. 2011;**94**(7):3288-3294

Inflammatory Bowel Diseases. 2001;**7**(2):136-145

and Insulin Resistance. Mediators of Inflammation. 2013;**2013**:1-13


[25] DiRienzo D. Effect of probiotics on biomarkers of cardiovascular disease: implications for heart-healthy diets. Nutrition Reviews. 2013;**72**(1):18-29

[11] Nagatomo Y, Tang W. Intersections Between Microbiome and Heart Failure: Revisiting

[12] Ryan P, Ross R, Fitzgerald G, Caplice N, Stanton C. Functional food addressing heart health. Current Opinion in Clinical Nutrition and Metabolic Care. 2015;**18**(6):566-571 [13] Sun J, Buys N. Effects of probiotics consumption on lowering lipids and CVD risk factors: A systematic review and meta-analysis of randomized controlled trials. Annals of

[14] Tomaro-Duchesneau C, Saha S, Malhotra M, Jones M, Rodes L, Prakash S. Lactobacillus fermentum NCIMB 5221 and NCIMB 2797 as cholesterol-lowering probiotic biothera-

[15] Hariri M, Salehi R, Feizi A, Mirlohi M, Ghiasvand R, Habibi N.A randomized, double-blind, placebo-controlled, clinical trial on probiotic soy milk and soy milk: effects on epigenetics and oxidative stress in patients with type II diabetes. Genes & Nutrition. 2015;**10**(6) [16] Ahn H, Kim M, Chae J, Ahn Y, Sim J, Choi I, et al. Supplementation with two probiotic strains, Lactobacillus curvatus HY7601 and Lactobacillus plantarum KY1032, reduces fasting triglycerides and enhances apolipoprotein A-V levels in non-diabetic subjects

[17] Schwingshackl L, Boeing H, Stelmach-Mardas M, Gottschald M, Dietrich S, Hoffmann G, et al. Dietary Supplements and Risk of Cause-Specific Death, Cardiovascular Disease, and Cancer: A Systematic Review and Meta-Analysis of Primary Prevention Trials.

[18] Miglioranza Scavuzzi B, Miglioranza L, Henrique F, Pitelli Paroschi T, Lozovoy M, Simão A, et al. The role of probiotics on each component of the metabolic syndrome and other cardiovascular risks. Expert Opinion on Therapeutic Targets. 2015;**19**(8):1127-1138

[19] Scott K, Antoine J, Midtvedt T, van Hemert S. Manipulating the gut microbiota to maintain health and treat disease. Microbial Ecology in Health & Disease. 2015;**26**(0)

[20] Ettinger G, MacDonald K, Reid G, Burton J. The influence of the human microbiome and

[21] Ishimwe N, Daliri E, Lee B, Fang F, Du G. The perspective on cholesterol-lowering mechanisms of probiotics. Molecular Nutrition & Food Research. 2015;**59**(1):94-105

[22] Tomaro-Duchesneau C, Jones M, Shah D, Jain P, Saha S, Prakash S. Cholesterol Assimilation by Lactobacillus Probiotic Bacteria: AnI n Vitro Investigation. BioMed

[23] Mafra D, Lobo J, Barros A, Koppe L, Vaziri N, Fouque D. Role of altered intestinal microbiota in systemic inflammation and cardiovascular disease in chronic kidney disease.

[24] Heim KC, Gustafson C. Effects of gut microbiome on cardiovascular health. Alternative therapy health medicine. Alternative therapy health medicine. 2014;**20**(suppl 1):62-64

the Gut Hypothesis. Journal of Cardiac Failure. 2015;**21**(12):973-980

peutics: in vitro analysis. Beneficial Microbes. 2015;**6**(6):861-869

with hypertriglyceridemia. Atherosclerosis. 2015;**241**(2):649-656

Advances in Nutrition: An International Review Journal. 2017;**8**(1):27-39

probiotics on cardiovascular health. Gut Microbes. 2014;**5**(6):719-728

Research International. 2014;**2014**:1-9

Future Microbiology. 2014;**9**(3):399-410

Medicine. 2015;**47**(6):430-440

66 Probiotics - Current Knowledge and Future Prospects


[39] Moroti C. Souza Margi Loyanne Francine, Costa Marcela de Rezende, Cavallini D. Sivieri K. Effects of the consumption of a new symbiotic shake on glycemia and cholesterol levels in elderly people w/type 2 diabetes mellitus. Lipids in Health and Disease. 2012;**11**(29)

**Chapter 4**

**Provisional chapter**

**Probiotic Applications in Autoimmune Diseases**

**Probiotic Applications in Autoimmune Diseases**

DOI: 10.5772/intechopen.73064

Evidences from animal models and humans have implied the involvement of alterations in the gut microbiota in development of some autoimmune diseases. Dysbiosis observed in autoimmune diseases is associated with decreased bacteria function and diversity, impaired epithelial barrier function, inflammation, and decreased regulatory T cells in the gut mucosa. Studies suggest that probiotics influence systemic immune responses, ensure the homeostasis of the healthy microbiota in the intestinal mucosa, and could, therefore, be used as adjuvant therapy to treat immune-mediated diseases. The mechanisms proposed to achieve this include mucus secretion; antimicrobial peptide production; the maintenance of the function of the gastrointestinal-epithelial barrier, ensuring adequate interactions between the gut microbiota and the mucosal immune cells; and, finally, helping the activation of host immune system in response to pathobionts. Here, we described several reports concerning probiotic applications in several animal models of autoimmune diseases and data of the main clinical trials concerning the applicability of probiotics in type 1 diabetes, multiple sclerosis, rheumatoid arthritis, and systemic

**Keywords:** dysbiosis, barrier disruption, inflammation, autoimmunity, probiotics

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

Thousands of years ago, Hippocrates, father of medicine, coined the concept that food would serve as medicine and postulated, "Let food be thy medicine, and let medicine be thy food." Nowadays, the concept of food as a medicine appeared as functional foods, referring to any foods or ingredients with nutritional value and that promote a health benefit to the host [1]. Probiotics, prebiotics, and synbiotics are the most popular ingredients used as functional

Gislane L.V. de Oliveira

**Abstract**

lupus erythematosus.

foods and dietary supplements [2].

**1. Introduction**

Gislane L.V. de Oliveira

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.73064


**Provisional chapter**
