key: cord-0003820-732xcksz authors: Nixon, Sophie L.; Rose, Lindsay; Muller, Annika T. title: Efficacy of an orally administered anti‐diarrheal probiotic paste (Pro‐Kolin Advanced) in dogs with acute diarrhea: A randomized, placebo‐controlled, double‐blinded clinical study date: 2019-03-18 journal: J Vet Intern Med DOI: 10.1111/jvim.15481 sha: 543ac2431685616436dfe9f7ff063a02a741686f doc_id: 3820 cord_uid: 732xcksz BACKGROUND: Acute diarrhea is a common clinical presentation of dogs. The effect of specific anti‐diarrheal probiotic pastes (ADPPs) in the management of acute, uncomplicated diarrhea in dogs is unknown. HYPOTHESIS: Administration of an ADPP containing Enterococcus faecium 4b1707 will improve the clinical outcome of acute, uncomplicated diarrhea in dogs compared to placebo. ANIMALS: One hundred forty‐eight client‐owned dogs with acute diarrhea as the main clinical sign. METHODS: Double‐blinded, placebo‐controlled, randomized, blocked, multicenter clinical field study conducted at 14 primary care veterinary practices in the United Kingdom and Ireland. RESULTS: The ADPP was associated with better clinical outcome compared to placebo in dogs with acute, uncomplicated diarrhea. Dogs in the ADPP group had a significantly shorter duration of diarrhea (ADPP: median, 32 hours; 95% confidence interval [CI], 2‐118; n = 51; Placebo: median, 47 hours; 95% CI, 4‐167; n = 58; P = .008) and the rate of resolution of diarrhea was 1.60 times faster in the ADPP group than in the Placebo group (ratio, 1.60; 95% CI, 1.08‐2.44; P = .02). Fewer dogs required additional medical intervention (AMI) for non‐improvement or worsening in the ADPP group compared to the Placebo group (3.5% of dogs and 14.8% of dogs, respectively), with a relative risk of 0.88 (P = .04; AMI, ADPP, 3.5%, 2/57 dogs; Placebo, 14.8%, 9/61 dogs; relative risk, 0.88; 95% CI, 0.77‐0.99). CONCLUSION AND CLINICAL IMPORTANCE: The ADPP may accelerate resolution of acute diarrhea in dogs and decrease the requirement for AMI. Acute diarrhea represents the most common cause of nonroutine veterinary visits for dogs in the United Kingdom and the United States. [1] [2] [3] [4] Acute diarrhea constitutes a short-term increase in fecal water content and consequently fecal fluidity, volume, and frequency of defecation. 5 Although acute diarrhea tends to be self-limiting, it represents an impaired state of health for the dog, a source of stress and inconvenience for the owner, and a potential zoonotic risk. In a recent study of dogs with acute diarrhea in the United Kingdom, the most common treatments were dietary modification (66% of cases) and antimicrobial treatment (63% of cases). 1 Previous studies have reported that up to 71% of dogs with acute diarrhea are treated with antimicrobials 3 despite emerging evidence that antimicrobial treatment is not effective in dogs with hemorrhagic or uncomplicated acute diarrhea. 6, 7 Consequently, acute diarrhea represents a considerable portion of antimicrobial usage in veterinary practice. Recent evidence suggests that the fecal microbiome is altered in dogs with acute diarrhea, [8] [9] [10] identifying modulation of the microbiome as a potential therapeutic target. Probiotics and prebiotics are defined as live microorganisms that confer a health benefit to the host when delivered in adequate amounts 11 and substrates that selectively promote the growth of microorganisms that confer a health benefit, 12 respectively. There is evidence that probiotics and prebiotics are capable of altering the microbiome of dogs. [13] [14] [15] [16] [17] [18] [19] [20] Probiotics and prebiotics favorably modulate gastrointestinal health by diverse mechanisms, but few studies have investigated the mechanism of action of putative probiotics in dogs. [21] [22] [23] [24] [25] [26] In predominantly in vitro, ex vivo, and rodent studies, probiotics and prebiotics have been shown to inhibit the growth of gastrointestinal pathogens, [27] [28] [29] [30] [31] [32] to improve gastrointestinal barrier function, and to favorably modulate the immune system. [33] [34] [35] [36] The extent to which these findings can be extrapolated to dogs is unknown. There is growing evidence in both the human and veterinary medical fields for the therapeutic potential of probiotics and prebiotics in treating and preventing acute diarrhea. A meta-analysis of 63 studies found that the administration of probiotics shortened the duration of clinical signs and decreased stool frequency in acute infectious diarrhea in humans. 37 44 Despite a lack of evidence for strain E. faecium 4b1707 in the treatment of acute diarrhea in dogs, antidiarrheal probiotic pastes (ADPPs) containing this probiotic are available. Our aim was to characterize the effect of a commercially available ADPP containing E. faecium 4b1707 (Pro-Kolin Advanced; PKA) on the clinical outcome of dogs with acute diarrhea. Specifically, we sought to identify whether the ADPP was associated with a shorter duration of acute diarrhea and a decrease in the number of dogs requiring additional medical intervention (AMI). The study was a double-blinded, placebo-controlled, randomized, multicenter clinical field study conducted at 11 primary care veterinary practices in the United Kingdom and 3 in Ireland. Block randomization was performed with a block size of 2 stratified by site of recruitment. Dogs were included in the study if they were presented to the veterinary surgeon for acute diarrhea with an owner-reported episode of diarrhea on ≥1 occasions in the 24 hours before presentation to the veterinarian. The cause of diarrhea was not investigated. Dogs were excluded from the study if their clinical signs were deemed unsuitable for conservative management by the attending veterinary surgeon or if they had received antibiotic or probiotic treatment in the 4 weeks before Day 0 of the study. A full list of inclusion and exclusion criteria is presented in the Supporting Information S1. Ethical approval was obtained from an independent welfare representative of Charles River Laboratories (Tranent, UK). A sample size of 43 cases per group was required based on the primary objective of identifying a difference in equality of survival curves in the proportion of dogs being free from diarrhea on day 3 using a 2-sided log rank test with a significance level of P < .05 and power of 80%; therefore, a target of 50 cases per group was set. The sample size calculation was based on 80% of dogs in the ADPP group and 50% of dogs in the Placebo group being free from diarrhea on Day 3. One hundred forty-eight dogs that fulfilled the inclusion criteria and none of the exclusion criteria were enrolled in the study and randomly assigned to receive either the ADPP (ADPP group) or a placebo paste (Placebo group) in a ratio of 1 : 1. The ADPP was a paste for PO administration containing E. faecium 4b1707, Preplex prebiotic, combined kaolin and montmorillonite clay, psyllium, pectin, and beta glucan (PKA; Protexin Veterinary, Somerset, UK). The placebo was indistinguishable in packaging, appearance, and sensory properties from the ADPP to study personnel. The ADPP and placebo were dosed q8h according to the dogs' body weight on Day 0. Details of the ADPP and placebo composition and the dosing regimen can be found in Supporting Information S2. All dogs received concurrent treatment with a highly digestible diet (Hills i/d, Topeka, Kansas) in place of their usual food. Dogs were treated with both the PO administered paste and diet until the dog had either completed or was withdrawn from the study, up to a maximum of 10 days, with completion defined as the passage of 3 consecutive feces of normal consistency. The primary efficacy criterion was duration of diarrhea, and a secondary efficacy criterion was the proportion of dogs withdrawn for AMI because of non-improvement or deterioration. Withdrawal for AMI and subsequent treatment was decided by the dog's owner and the attending veterinarian. Dogs enrolled in the study were processed according to the study procedures described in Figure 1 . In brief, clinical examination was performed on Day 0, and owners of dogs enrolled in the study were given the ADPP or placebo syringes to administer q8h starting immediately, and diaries in which they were instructed to record the date, time, and consistency of all feces passed by their dog for the duration of the study. Fecal consistency scoring was performed using a scale of 1 (hard) to 6 (watery) based on a modification of the Nestle-Purina scoring system in which scores 1 (hard) and 2 (firm) of the Nestle-Purina system were combined. 45 Scores ≤3 were defined as normal and scores ≥4 were defined as diarrhea. Owners were provided with both a text and pictorial description for each score ( Figure 1A Owners, veterinarians, and the study monitor were blinded to the contents of the syringe. Dogs with comorbidities were included if it was believed that neither their underlying disease nor any treatment that they were receiving would be expected to affect the course of acute diarrhea. Concomitant medications that dogs received in the study for unrelated problems are listed in Supporting Information S4. Statistical analyses of data were performed using GraphPad Prism With the exception of dogs that were removed for non-improvement or deterioration, diarrhea resolved in all dogs within 167 hours (7 days Dogs that experienced non-improvement or deterioration were withdrawn from the study for AMI. Treatment to be given as AMI was F I G U R E 2 Summary of number of dogs recruited or excluded as part of the study. A total of 148 dogs were enrolled onto the study and diarrhea resolved (study completion) in 107 dogs. The majority of dogs that failed to complete the study did so due to errors related to dosing of the ADPP or placebo. A small number of dogs in both the ADPP and Placebo groups were withdrawn for medical intervention due to worsening or non-improvement, and these were included in the efficacy analysis. ADPP, anti-diarrheal probiotic paste Treatment with the ADPP compared to placebo in dogs with acute, uncomplicated diarrhea led to a decrease in the duration of diarrhea and a decrease in the requirement for AMI because of non-improvement or deterioration. Existing evidence suggests that probiotics can exert a beneficial effect on gastrointestinal health in dogs. 16 Probiotics have been shown to accelerate the resolution of nonspecific acute diarrhea, [41] [42] [43] improve the outcome of parvoviral enteritis in puppies, 46 Compliance with the ADPP was high and comparable with the study diet. Fewer than 3% of owners involved in the study were unable to administer either the study diet or the ADPP or placebo pastes. In order for the study to accurately reflect field conditions, dogs that missed doses of the ADPP or placebo were not censored in the analysis, provided they had not missed >2 doses on a single day and providing the dosing interval did not exceed 24 hours. Our results should be interpreted in the context of limitations in the study design. First, it was assumed that the placebo paste would have no effect on the outcome of acute diarrhea, but differences in the macronutrient profile of the ADPP and placebo could have influenced the duration of diarrhea. For example, the fat content of the placebo was slightly lower than that of the ADPP (39% and 42%, respectively). A low-fat diet is commonly recommended in dogs with acute diarrhea because of the effect of dietary fat on gastrointestinal motility and the possibility that undigested fat in the colon could exacerbate diarrhea. [50] [51] [52] [53] However, the small difference in fat content between the ADPP and placebo was deemed unlikely to affect clinical outcome in the context of the total dietary intake of macronutrients. Secondly, it is likely that the duration of diarrhea was affected by the management of the dog, because the frequency with which dogs were provided with the opportunity to defecate outside was likely to affect the time of defecation. It was presumed that both groups would be equally affected, but it is possible that substantial differences between the 2 groups in the management of dogs (eg, more owners in 1 group working away from home) could have confounded the study findings. The ADPP was palatable and safe in dogs with acute diarrhea. Dogs receiving the ADPP experienced a small decrease in the duration of diarrhea and a decrease in the requirement for AMI because of deterioration or non-improvement of diarrhea. The ADPP represents a novel product that exerts some clinical benefit in the management of dogs with acute diarrhea. S. L. Nixon is employed by ADM Protexin Ltd and L. Rose is a past employee of ADM Protexin Ltd. The study was funded by ADM Protexin Ltd who manufactures Pro-Kolin Advanced. Authors declare no off-label use of antimicrobials. The study was approved by an independent animal welfare representative. There were no objections to the conduction of the study. Before the start of the study, each owner was informed about the study objectives and signed an owner consent form. The study design did not include any painful procedure in the study animals. Authors declare human ethics approval was not needed for this study. Sophie L. 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