Preterm Infant Gut (PINGU) - a Norwegian Multi Centre Study (PINGU)

Gut Microbiome Study in Preterm Infants - a Norwegian Multi Centre Study

Necrotizing enterocolitis (NEC) is a leading cause of morbidity and mortality among infants in the neonatal intensive care unit (NICU). It has been postulated that abnormal colonization of the preterm gut, or an unfavorable balance between gut bacteria may contribute to the development of NEC.

Recent clinical randomized studies and meta-analysis have shown that proactive colonization of probiotic bacteria reduce the frequency of NEC. Based on this evidence, in April 2014 all Norwegian NICUs started routinely administration of probiotics to all extremely premature neonates susceptible to NEC (gestational age <28 weeks/birth weight <1000g).

The current project is investigating the gut microbiome in patients receiving probiotics and compare the the gut microbiome with moderate premature infants not receiving probiotics. In addition, we are including a control of healthy full-term infants.

Samples containing feces from participants will be analyzed by state of the art whole-genome sequencing techniques. Bacterial diversity will be analysed with bioinformatic tools.

Study hypotheses:

• Probiotics given to extremely preterm infants will change the biodiversity of the gut microflora.
• Antibiotics given to these patients may influence the gut microflora also in infants receiving probiotics. In particular use of vancomycin may change the gut flora.
• After cessation of probiotic prophylaxis the gut flora of infants receiving probiotics will gradually resemble the gut flora of infants not receiving probiotics.
• A cross-contamination of probiotic bacteria between patients treated with probiotics and patients not treated with antibiotics may occur.

Study Overview

• Status: Completed
• Conditions: Mixed Flora; Infection

Detailed Description

Necrotizing enterocolitis (NEC) is a leading cause of morbidity and mortality among infants in the neonatal intensive care unit (NICU). Prematurity is the most important risk factor for NEC. The pathogenesis of NEC remains unclear, and prevention and treatment strategies are limited. It has been postulated that abnormal colonization of the preterm gut, or an unfavorable balance between gut bacteria, is significant in the pathogenesis of NEC.

Recent clinical randomized studies and meta-analysis have shown that proactive colonization of probiotic bacteria reduce the frequency of NEC. Based on this evidence, in April 2014 all Norwegian NICUs started routinely administration of probiotics to all extremely premature neonates susceptible to NEC (gestational age (GA) <28 weeks/birth birth weight (BW) <1000 g).

The current project is investigating the gut microbiome in patients receiving probiotics and compare the the gut microbiome with moderate premature infants not receiving probiotics. In addition, we are including a control of healthy full-term infants.

Samples containing feces from participants will be analyzed by state of the art whole-genome sequencing techniques. Bacterial diversity and taxonomy will be analysed using bioinformatic tools

Inclusion criteria:

• Preterm infants 24-27 weeks gestation/ birth weight < 1000 g receiving probiotics
• Preterm infants 28-31 weeks gestation/BW 1000-1500 g not receiving probiotics
• Healthy term infants

Exclusion criteria

• Preterm infants < 24 weeks gestation
• Preterm infants < 32 weeks with severe lethal complication/poor prognosis around 1 week of age
• Infants with severe congenital malformations

Fecal samples will be obtained:

• 1 week of age
• 4 weeks of age
• 4 months corrected age
• 12 months corrected age

Study hypotheses:

• Probiotics given to extremely preterm infants will change the biodiversity of the gut microflora.
• Antibiotics given to these patients may influence the gut microflora also in infants receiving probiotics. In particular use of vancomycin may change the gut flora.
• After cessation of probiotic prophylaxis the gut flora of infants receiving probiotics will gradually resemble the gut flora of infants not receiving probiotics.
• A cross-contamination of probiotic bacteria between patients treated with probiotics and patients not treated with antibiotics may occur.

This is an explorative study. No formal sample size assessment is possible. Sequencing costs will be substantial. We will limit the number of participants to 26 x 2 preterm infants and 10 control healthy infants.

Six Norwegian Neonatal Intensive care units wil participate in the study.

• Study Type: Observational
• Enrollment (Actual): 60

Contacts and Locations

Study Locations

• Norway
  • Bergen, Norway, 5021
    • Haukeland Universtiy Hospital
  • Oslo, Norway, 0424
    • Oslo University Hospital, Rikshospitalet
  • Oslo, Norway
    • Ahus University Hospital
  • Oslo, Norway, 0424
    • Oslo University Hospital, Ullevaal
  • Stavanger, Norway, 4011
    • Stavanger University Hospital
  • Tromsø, Norway, 9038
    • University Hospital of North Norway
  • Trondheim, Norway, 7030
    • St Olavs Hospital, Trondheim University Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 1 hour to 1 year (CHILD)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Preterm infants hospitalized in 6 Norwegian NICUs; divided in one group extremely preterm infants receiving probiotics and one group moderate preterm infants not receiving antibiotics. A group of helathy infants from the post-natal ward will also be included

Description

Inclusion Criteria:

• Preterm infants with gestational age 24-27 weeks/birth weight < 1000 g, treated with probiotics (target number 26)
• Preterm infants with gestational age 29-31 weeks/birth weight 1000-1500 g, not treated with probiotics (target number 26)
• Term infants (target number 10)

Exclusion Criteria:

• Extremely preterm infants with gestational age below 24 weeks
• Preterm infants (24-31 weeks) with life threatening complications during 1 week of age
• Infants with congenital malformations

Study Plan

How is the study designed?

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort
Probiotics; Preterm infants given probiotics: GA 24-27 weeks/Birth weight < 1000 g Preterm infants not given probiotics: GA 28-31 weeks/Birth weight 1000-1500 g Full-term infants not given probiotics (control)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
To assess gut microbiome composition (meta genome sequencing) of preterm infants receiving probiotics versus preterm infants not receiving probiotics	Stools samples from preterm infants and term infants (control)	4 time points: 7 days of age, 4 weeks of age, 4 months corrected age and 12 months corrected age

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Impact of antibiotic exposure on gut microbiome	Stool samples from preterm and term infants	4 time points: 7 days of age, 4 weeks of age, 4 months corrected age and 12 months corrected age

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Cross contamination of probiotic bacteria in a NICU	Detection of probiotic bacterial microbiome profiles in children not receiving probiotics	7 days of age and 4 weeks of age

Collaborators and Investigators

• Sponsor: University Hospital of North Norway
• Collaborators: Ullevaal University Hospital; Oslo University Hospital; University of Tromso; Helse Stavanger HF; Haukeland University Hospital; St. Olavs Hospital
• Investigators: Study Chair: Claus Klingenberg, MD.phD.Prof., University Hospital of North Norway; Principal Investigator: Eirin Esaiassen, MD, University Hospital of North-Noway

Publications and helpful links

General Publications

• Berrington JE, Stewart CJ, Cummings SP, Embleton ND. The neonatal bowel microbiome in health and infection. Curr Opin Infect Dis. 2014 Jun;27(3):236-43. doi: 10.1097/QCO.0000000000000061.
• Stewart CJ, Marrs EC, Magorrian S, Nelson A, Lanyon C, Perry JD, Embleton ND, Cummings SP, Berrington JE. The preterm gut microbiota: changes associated with necrotizing enterocolitis and infection. Acta Paediatr. 2012 Nov;101(11):1121-7. doi: 10.1111/j.1651-2227.2012.02801.x. Epub 2012 Aug 31.
• Esaiassen E, Hjerde E, Cavanagh JP, Pedersen T, Andresen JH, Rettedal SI, Stoen R, Nakstad B, Willassen NP, Klingenberg C. Effects of Probiotic Supplementation on the Gut Microbiota and Antibiotic Resistome Development in Preterm Infants. Front Pediatr. 2018 Nov 16;6:347. doi: 10.3389/fped.2018.00347. eCollection 2018.

Study record dates

Study Major Dates

• Study Start: March 1, 2015
• Primary Completion (Actual): November 1, 2015
• Study Completion (Actual): November 1, 2015

Study Registration Dates

• First Submitted: July 21, 2014
• First Submitted That Met QC Criteria: July 21, 2014
• First Posted (Estimate): July 22, 2014

Study Record Updates

• Last Update Posted (Actual): March 11, 2019
• Last Update Submitted That Met QC Criteria: March 7, 2019
• Last Verified: June 1, 2016

More Information

Terms related to this study

• Keywords: Antibiotics; Gut microbiome; Necrotizing enterocolitis
• Other Study ID Numbers: 2014/930 (REK)

Plan for Individual participant data (IPD)

Study Data/Documents

1. Clinical Study Report
   Information comments: Publication from this study