Lower gastrointestinal tract dysbiosis in persistent critical illness: a systematic review

Introduction. The human lower gastrointestinal tract microbiome is complex, dynamic and prone to disruption occurring during critical illness.Hypothesis or gap statement. The characteristics of lower gastrointestinal tract microbiome disruption and its association with clinical outcomes in patients with prolonged intensive care stay remain uncertain.Aim. To systematically review studies describing lower gastrointestinal tract molecular sequencing in patients with prolonged intensive care stay and explore associations with clinical outcomes.Methodology. This systematic review was prospectively registered and follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. OVID MEDLINE, EMBASE and The Cochrane Central Register of Controlled Trials databases were searched for eligible studies describing adults and/or children who underwent molecular sequencing of stool or rectal samples taken on or after 10 days of intensive care.Results. There were 13 studies with 177 patients included. The overall certainty of evidence was low, and no studies reported mortality. Reduced alpha diversity was observed in nine out of nine studies but was not associated with clinical outcomes in four out of four studies. Longitudinal alpha diversity decreased in five out of six studies, and inter-individual beta diversity increased in five out of five studies. After approximately one week of intensive care unit admission, rapid fluctuations in dominant taxa stabilized with trajectories of either recovery or deterioration in five studies. Pathogenic enrichment and commensal depletion were reported in all 13 studies and associated with clinical outcomes in two studies.Conclusion. Lower gastrointestinal tract microbiome disruption is highly prevalent and has consistent characteristics in patients with prolonged intensive care stay. Amongst reported metrics, only relative taxon abundance was associated with clinical outcomes.