L’administration d’aliments fonctionnels contenant des cellules probiotiques est une des voies de rétablissement de l'équilibre du microbiota. Pour assurer la protection des probiotiques pendant la transformation des aliments et le passage gastro-intestinal, l'encapsulation est essentielle. Nous proposons ici des supports hybrides à base de silice en tant que nouveaux systèmes d’encapsulation de probiotiques. Lactobacillus rhamnosus GG (LGG) a été choisi comme modèle de bactéries probiotiques et l'alginate comme polymère prébiotique. Deux types de supports ont été préparés, soit par émulsification, soit par électrospraying: (i) des billes hybrides de 10-30 μm dans lesquelles les bactéries étaient en contact direct avec un mélange d'alginate et de silice et (ii) des particules cœur-couronne de 200-600 μm dans lesquelles les bactéries sont d'abord encapsulées dans un gel d'alginate, puis recouvertes d'une couche de silice. La viabilité des LGG a été efficacement maintenue seulement dans les particules cœur-couronne, dans lesquelles LGG n’ont pas était directement exposées à la silice. Ces prototypes cargo ont permis la protection de LGG pendant le stockage dans la bière ou le jus de pomme, ainsi que pendant le passage à travers le tractus gastro-intestinal. En outre, les LGG libérées dans un écosystème fécal se sont multipliées au détriment des autres membres de la communauté de Lactobacilli. Cette étude offre donc une preuve de concept quant à la potentialité des systèmes hybrides silice/biopolymère pour l'administration orale de bactéries probiotiques / One way to reestablish the microbiota equilibrium is to administrate a functional food containing probiotic cells. To insure protection of the living matter during the food processing and the gastrointestinal passage, encapsulation is essential. Herein we propose silica-based hybrid carriers as new probiotic delivery systems. Lactobacillus rhamnosus GG (LGG) was chosen as a model probiotic bacteria and alginate as prebiotic polymer. Two types of carriers were prepared either by emulsification or by electrospraying: (i) hybrid beads of 10-30 m in which the bacteria was in direct contact with a mixture of alginate and silica and (ii) core-shell beads of 200-600 m in which the bacteria are first embedded in an aqueous core of alginate, then coated with a silica shell. The viability of LGG was efficiently maintained only in core-shell particles, in which LGG was not directly exposed to silica. Those core-shell prototype carriers allowed the protection of LGG during storage in beer or apple juice, and during the passage through the gastrointestinal tract. Additionally the LGG released in the colon outcompete other members of the Lactobacilli community and it was able to thrive within a fecal ecosystem. This study offers thus a proof of concept for the potential use of hybrid silica/biopolymer systems in oral delivery of probiotic bacteria

Department of Animal Science / MSCAGR (Animal Science)

No description available.

No description available.

Objetivo: Evaluar la viabilidad de bacterias ácido lácticas y levaduras y composición nutricional del kéfir de leche durante su almacenamiento en refrigeración. Metodología: Fue un estudio experimental de laboratorio, desarrollado en cuatro etapas. En la primera, se realizó la elaboración de la bebida. La segunda etapa abarcó los análisis físico-organoléptico y fisicoquímico. La tercera etapa implicó el recuento de BAL y levaduras en la bebida refrigerada durante los días 1, 7 y 20. En la última etapa, se llevó a cabo el análisis químico-proximal del kéfir refrigerado al día 20. Resultados: Los resultados del recuento de BAL mostraron viabilidad de las mismas en los tres periodos de almacenamiento en frío, sin embargo, su variación no fue significativa. Con respecto a las levaduras, estas se mantuvieron viables hasta el día 7, pues tras ocurrir una disminución de hasta 3 Log (UFC/ml), su recuento al día 20 fue inferior al mínimo establecido como adecuado según las normativas. Conclusiones: Las muestras de kéfir de leche almacenadas en frío (5 a 7°C) presentaron valores de BAL y levaduras dentro de lo establecido por las normas internacionales vigentes, a excepción del recuento de levaduras en el día 20. El análisis químico proximal del kéfir demostró un bajo contenido de energía, grasa, carbohidratos y lactosa, por lo que se recomienda que la población intolerante a la lactosa pueda consumir esta bebida. / Objective: To evaluate the viability of lactic acid bacteria, yeasts and the nutritional composition of milk kefir during its refrigerated storage. Methodology: This laboratory experimental investigation was developed in four parts. In the first phase, the kefir drink was elaborated. The second phase involved its physico-chemical and organoleptic analysis. The third phase entailed the count of LAB and yeasts in the refrigerated kefir drink during days 1, 7, and 20. In the last part, the 20 days refrigerated kefir was proximal- chemical analyzed. Results: The results of the BAL count shown viability of itselve in the trhee periods of cold storage, their variation was non-significant. Regarding the yeasts, these remained viable until day 7, because after a decrease of up to 3 Log (CFU / ml) occurred, their count on day 20 was lower than the minimum established as adequate according to the regulations. Conclusions: The milk kefir samples stored cold (5 to 7°C) showed BAL and yeast values that were mostly within the established by the current regulations, with the exception of the yeast count on day 20. Likewise, the proximal-chemical analysis of kefir showed a low content of energy, fat, carbohydrates, and lactose so it is recommended that the lactose intolerant population could consume this drink. / Tesis

The prevalence of non-alcoholic fatty liver disease (NAFLD) in children has increased over the past decades, creating a need for animal models that recapitulate the features of the pediatric disease. Iberian pigs have a leptin-resistant phenotype characterized by hyperleptinemia, hyperphagia, and extreme adipogenesis. We hypothesized that neonatal Iberian pigs fed a high fat high-fructose (HFF) diet will develop a pattern of liver injury resembling pediatric NAFLD. In addition, we sought to determine if a mixture of probiotics would prevent the disease. Animals were fed 1 of 4 diets containing (g/kg body weight × d) 0 g fructose, 11 g fat and 199 kcal (CON-N; n=8), 22 g fructose, 16 g fat and 300 kcal (HFF2-N; n=8), CON + probiotic (CON-P; n=6), or HFF2 + probiotic (HFF2-P; n=6) every 6 h for 70 d. The probiotic mixture (6.2 × 104 cfu/mL) contained Pediococcus acidilactici, Pediococcus pentosaceus, Lactobacillus plantarum and Bacillus amyloliquefaciens. Body weight was recorded every 3 d. Serum markers of liver injury and dyslipidemia were measured on d 40 and 65 at 2 h post feeding. Fasting leptin, insulin, glucose and homeostatic model assessment (HOMA) values were assessed on d 70. Liver and skeletal muscle (longissimus dorsi) were collected on d 70 for histology, triacylglyceride (TAG) quantification, relative gene expression, and Western blot analysis. Metabolomic analysis was performed on liver tissue and plasma. Body weight was not significantly greater in HFF fed pigs compared to CON. Leptin, alanine and aspartate aminotransferases, alkaline phosphatase, lactate dehydrogenase and total bilirubin were increased (P ≤ 0.001), and high and low density lipoproteins decreased (P ≤ 0.05) in HFF2-N and HFF2-P. Livers in HFF2-P and HFF2-N had higher relative weight and TAG (P ≤ 0.001), micro and macrovesicular steatosis, ballooning degeneration, Mallory-denk bodies, inflammation and necrosis, increased gene expression of TNFα, TGFβ, IL1α and PPARγ (P ≤ 0.001), and decreased ChREBP (P ≤ 0.001). A probiotic affect was seen as pigs fed CON-P and HFF2-P had higher insulin and HOMA values were increased (P ≤ 0.05). Western blot analysis showed dysregulation of autophagy in liver of pigs fed CON-P and HFF2-P, and in skeletal muscle of pigs fed CON-N and HFF2-N. Metabolomic analysis demonstrated dysregulation of one-carbon metabolism, the tricarboxylic acid cycle (TCA), the urea cycle, and amino acid metabolism of pigs fed HFF2 diets compared to CON diets. In conclusion, Iberian pigs fed a HFF diet recapitulate many pediatric NAFLD-associated features, in the absence of obesity and independently of probiotic supplementation, suggesting a potentially suitable model for pediatric NAFLD research. Furthermore, probiotic supplementation did not ameliorate the onset of NAFLD when fed in conjunction with a HFF diet.

Le cancer colorectal (CCR) est le 3ème plus diagnostiqué au Canada. Son traitement implique une résection chirurgicale du côlon ou du rectum, et une reconnexion des deux bouts intestinaux pour rétablir la continuité gastrointestinale. Cette reconnexion, appelée « anastomose », peut ne pas bien guérir chez jusqu’à 30% des patients, ce qui mène à une complication morbide et mortelle appelée « fuite anastomotique ». En plus de diminuer la survie et la qualité de vie, la fuite est possiblement associée à une récidive accrue du cancer pour des raisons qui demeurent obscures. Malgré des progrès techniques importants dans les dernières décennies, les taux de fuite n’ont pas significativement diminué, et sa survenue demeure hautement imprévisible. Des données récentes ont suggéré que le microbiote intestinal, ou la collection de microorganismes dans l’intestin, peut influencer le processus de guérison après la chirurgie, mais l’évidence sur cette relation reste faible. Les études suivantes visaient donc à évaluer le lien causal entre le microbiote, la fuite anastomotique le CCR. En utilisant des échantillons de selles collectés avant la chirurgie de 18 patients avec CCR (9 avec fuite et 9 sans fuite), on a évalué le rôle causal du microbiote humain chez des souris assujetties à une greffe de microbiote fécal (GMF) puis une chirurgie colique. On a trouvé que la GMF avec des échantillons de patients avec fuite a entrainé chez la souris une mauvaise guérison anastomotique, un affaiblissement de la matrice extracellulaire dans la plaie colique, et une inflammation accrue localement. On a identifié 2 souches bactériennes, Parabacteroides goldsteinii kh35 et Alistipes onderdonkii kh33, qui influençaient la guérison anastomotique, la 1ère positivement et la 2ème négativement. Ces souches modulaient l’inflammation dans la muqueuse colique, avec P. goldsteinii exerçant un effet anti-inflammatoire et A. onderdonkii un effet pro-inflammatoire. En utilisant des échantillons de muqueuses collectés de patients avant la complétion de l’anastomose, on a trouvé avec une analyse multiplex que les patients présentant une fuite avaient des niveaux basaux plus élevés des macrophage inflammatory protein-1 alpha, monocyte chemoattractant protein-1, macrophage inflammatory protein 2 et interleukin-17A/F, et que le microbiote de ces patients entraine une augmentation similaire de ces cytokines pro-inflammatoires dans l’intestin des souris. Pour corroborer l’hypothèse que les patients présentant une fuite après la chirurgie avaient des niveaux basaux plus élevés d’inflammation intestinale de bas-grade induite par le microbiote, on a quantifié 9 cytokines dans la muqueuse colorectale de 77 patients avec CCR, pami lesquels 13 ont présenté une fuite après la chirurgie. Les 9 cytokines étaient plus élevées chez les patients ayant développé une fuite. On a exploré des marqueurs inflammatoires potentiels dans les selles, et qui peuvent être utilisés comme des biomarqueurs de dépistage avant la chirurgie, et avons identifié la calprotectine et la lipocaline-2 comme étant significativement différentes entre les patients présentant, ou pas, une fuite anastomotique. Ensuite, on a exploré si des métabolites bactériens peuvent être utilisés pour améliorer la guérison anastomotique. Les acides-gras à courte chaine (AGCCs) sont produits dans le côlon après la fermentation bactérienne de fibres alimentaires. On a ainsi testé si une supplémentation chez la souris avec de l’inuline ou des galacto-oligosaccharides (GOS), deux oligosaccharides fermentables, peut améliorer la guérison. On a trouvé que l’inuline et le GOS ont augmenté les niveaux du bénéfique AGCC butyrate, amélioré la guérison anastomotique, favorisé la réparation épithéliale, la déposition du collagène et la barrière intestinale. Enfin, puisque le butyrate est connu pour son effet anticancérigène via une activation peroxysome proliferator-activated receptor gamma (PPAR-γ), on a investigué la relation entre l’amélioration de la guérison intestinale postopératoire avec l’inuline et le 5-aminosalicylate (5-ASA), un activateur de PPAR-γ, et la récidive du CCR. Une revue de la survie postopératoire de patients avec CCR ayant, ou pas, présenté une fuite a été effectuée. L’effet d’une supplémentation alimentaire avec de l’inuline ou du 5-ASA sur les tumeurs anastomotiques a été évalué chez des souris subissant une chirurgie colique. L’inuline et le 5-ASA ont été aussi évalués dans un modèle murin de métastases hépatiques où les cellules de CCR étaient inoculées chirurgicalement dans la rate. Les patients présentant une fuite présentaient une survie globale et oncologique moindre que les patients sans fuite. Une mauvaise guérison anastomotique chez la souris a entrainé des tumeurs anastomotiques et péritonéales plus volumineuses. L’inuline et le 5-ASA ont renforcé la barrière intestinale et prévenu les tumeurs anastomotiques et dissémination métastatique chez la souris. Ces trouvailles renforcent l’hypothèse que prévenir la fuite améliore les issues oncologiques des patients avec CCR, et ouvre la voie à des essais cliniques où des interventions modifiant le microbiote seraient utilisées pour favoriser la guérison et diminuer la récidive du cancer. En résumé, on a démontré pour la première fois le lien causal entre le microbiote intestinal préopératoire et la guérison anastomotique chez les patients avec CCR. On a aussi identifié des biomarqueurs potentiels qui peuvent être utilisés en pratique pour détecter l’inflammation subclinique de bas-grade induite par le microbiote pour prédire la guérison avant la chirurgie. On a aussi démontré que le microbiote et PPAR-γ peuvent être modulés avec des oligosaccharides fermentables pour améliorer la guérison, renforcer la barrière intestinale et prévenir la récidive du cancer. / Colorectal cancer (CRC) is the third most diagnosed cancer in Canada. Its treatment involves a surgical resection of the colon or rectum, and a reconnection of the remaining bowel segments to re-establish gastrointestinal continuity. This reconnection, termed “anastomosis”, may fail to heal and leak in up to 30% of patients, which leads to a morbid and mortal complication called “anastomotic leak” (AL). In addition to decreasing survival and quality of life, AL may be linked to higher cancer recurrence for reasons that remain unclear. Despite significant technical progress over the last decades, the rates of AL have not significantly decreased, and its occurrence remains highly unpredictable. Recent data have suggested that the gut microbiota, or the collection of microorganisms in the gut, may influence the healing process after surgery, but evidence on this relation remains weak. The following studies aimed therefore at assessing the causal link between the gut microbiota, AL, and CRC in patients undergoing surgery. Using fecal samples collected before surgery from 18 patients with CRC (9 with AL and 9 without AL), we assessed the causal role of the human microbiota in mice subjected to fecal microbiota transplantation (FMT) then colonic surgery. We found that FMT from AL patients led to poor anastomotic healing, a weakened extracellular matrix in the colonic wound, and heightened inflammation locally. We identified 2 bacterial strains, Parabacteroides goldsteinii kh35 and Alistipes onderdonkii kh33, that were found to influence anastomotic healing, the first one positively and the second one negatively. These strains were found to modulate inflammation in the colonic mucosa, with P. goldsteinii exerting an anti-inflammatory effect and A. onderdonkii a pro-inflammatory effect. Using mucosal samples collected from patients before the completion of the anastomosis, we found with a multiplex assay that patients experiencing AL harbor higher basal levels of macrophage inflammatory protein- 1 alpha, monocyte chemoattractant protein-1, macrophage Inflammatory Protein 2 and interleukin-17A/F, and that the microbiota of these patients lead to the same increase in pro-inflammatory cytokines in mice. To corroborate the hypothesis that patients experiencing AL after surgery harbor higher basal levels of microbiota-driven low-grade inflammation in the gut, we quantified 9 cytokines in the colorectal mucosa of 77 patients with CRC, among whom 13 experienced AL after surgery. All 9 cytokines were found to be increased in patients developing AL. We explored potential fecal inflammatory markers that could be used as screening biomarkers before surgery, and identified calprotectin and lipocalin-2 as being significantly different between patients that subsequently developed, or not, AL. 4 Next we explored whether bacterial metabolites may be used to improve anastomotic healing. Short-chain fatty acids are produced in the gut upon bacterial fermentation of dietary fibers. We therefore tested in mice whether dietary supplementation with inulin or galacto-oligosaccharides (GOS), two fermentable oligosaccharides, could improve healing. We found that inulin and GOS increased the levels of the beneficial SCFA butyrate, improved anastomotic healing, promoted epithelial repair, collagen deposition and the gut barrier function. Finally, as butyrate is known to exert anticarcinogenic effect by stimulating the nuclear receptor peroxisome proliferator-activated receptor gamma (PPAR-γ), we further investigated the relationship between promotion of postoperative intestinal healing using inulin and 5-aminosalicylate (5-ASA), a PPAR-γ activator, and CRC recurrence. A review of postoperative survival of CRC patients with and without AL was performed. The effect of dietary supplementation with inulin and 5-ASA on local anastomotic tumors was assessed in mice undergoing colonic surgery. Inulin and 5- ASA were also assessed in a mouse model of liver metastasis where CRC cells are surgically inoculated into the spleen. Patients experiencing AL displayed significantly lower overall and oncological survival than non-AL patients. Poor anastomotic healing in mice led to larger anastomotic and peritoneal tumors. Inulin and 5-ASA reinforced the gut barrier and prevented anastomotic tumors and metastatic spread in mice. These findings reinforce the hypothesis that preventing AL improves oncological outcomes in patients with CRC, and pave the way towards clinical trials in which microbiotatargeted interventions may be used to enhance healing and diminish cancer recurrence. In summary, we demonstrated for the first time the causal link between the preoperative gut microbiota and anastomotic healing in patients with CRC. We also identified potential biomarkers that could be used in practice to detect microbiota-driven subclinical inflammation and predict healing before surgery. We also showed that the gut microbiota and PPAR-g could be modulated using fermentable oligosaccharides to improve healing, reinforce the gut barrier and prevent cancer recurrence.

<p>Parasite infections around the world are a huge economic burden and decrease the quality of life for many people. Probiotic bacteria are being investigated as a possible treatment for many enteric issues due to their beneficial effects by altering the immune system. Goblet cells are the main source of mucins in the gut, and play an important role in host defense. Alterations in goblet cells and mucin have been implicated in a number of gastrointestinal (GI) diseases and infections. The aim of this study is to develop a probiotic based strategy to modulate goblet cell function in relation to host defense in enteric infection. Utilizing a murine model of parasite infection, <em>Trichuris muris</em>,<em> </em>we examined the effect of daily administration with probiotic <em>Lactobacillus reuteri</em> in different strains of mice and investigation of goblet cell alterations, immune and inflammatory responses in gut, and host defense mechanisms.</p> <p>Treatment with<strong> </strong>live <em>L. reuteri</em> significantly enhanced worm expulsion in resistant C57BL/6 mice and this was associated with significant increase in goblet cells numbers and an increase in IL-10. This lead to investigation of the probiotic effects in IL-10 knock out (KO) and Muc2 KO mice during the infection. There was no difference of worm burden or goblet cell amounts in infected IL-10 KO mice infected treated with probiotic or medium. In infected Muc2 KO mice treated with <em>L. reuteri</em>, there was an earlier increase of goblet cells, and a corresponding decrease in worm numbers. Finally, assessment of this probiotic in susceptible ARK mice revealed no alterations in worm burden, but the treatment prevented the increase in IFN-γ and IL-1β and significantly increased goblet cell numbers.</p> <p>These data demonstrate that altering the flora with probiotic <em>L. reuteri</em> treatment can modulate intestinal goblet cell biology and immune responses in gut, and promote worm expulsion, possibly through an IL-10 mediated mechanism. The increases in goblet cell numbers may also play a role in the early expulsion of the parasite. In addition to enhancing our understanding on the beneficial effect of probiotics in host defense in enteric infection, this research provides new information on gut function in the context of goblet cells and mucins.</p> / Master of Science (MSc)

<p>Intestinal microbiota are key determinants of gut homeostasis and affect various gut physiological and immune processes. Co-evolution has enabled the host and intestinal microbes to exist in a mutualistic relationship. However, interactions between the host and its intestinal microbiota exist in a delicate balance between mutualism and pathogenicity. Maintenance or disruption of this balance depends on a complex interplay between the microbiota and the host, as well as other gut luminal factors, including diet, that are poorly understood. The main goal of this thesis has been to study the host-gut luminal interactions that regulate gut physiology and immunity. In particular, <strong>Chapter 2</strong> centers on investigating the effect of perturbing the intestinal barrier using a non-steroidal inflammatory drug on host-microbial and dietary interactions in a mouse model of gluten sensitivity. I demonstrated that indomethacin-induced increase in intestinal permeability is associated with altered intestinal microbiota composition, systemic antibody development against intestinal bacteria and a shift in immune responses to the dietary antigen, gluten. <strong>Chapter 3</strong> focuses on investigating whether modulation of the intestinal microbiota can affect the host’s susceptibility to intestinal injury. I used mice with defective intracellular bacterial receptor signaling because discrimination between commensals and pathogens is, in part, achieved by a family of receptors that recognize conserved bacterial components. I demonstrated that the microbiota with which these mice are colonized influences the expression of RegIII-γ, a type of antimicrobial peptide, and susceptibility to intestinal injury. To gain further insight on the effect of microbiota on antimicrobial peptides, in <strong>Chapter 4</strong> we conducted a combination of gnotobiotic and <em>in-vitro</em> experiments where we identified that specific components of the microbiota differentially regulate RegIII expression. Further examination showed that <em>MyD88 a</em>nd <em>Ticam1 </em>genes, which are signaling adaptor proteins of pattern recognition receptors, are essential regulators of microbial–induced RegIII expression by intestinal epithelial cells. Collectively, the work presented in this thesis provides novel insight on the bi-directional interaction between the host and the gut luminal content as well as of potential beneficial effects of microbiota-modulating strategies in maintaining homeostasis and preventing disease.</p> / Doctor of Philosophy (Medical Science)

Ventilator-associated pneumonia (VAP) is the most common healthcare-associated infection in the intensive care unit, resulting in a high burden of illness, mortality and increased cost. The literature around the cost-effectiveness of probiotics in prevention of health-care associated infections has not been previously well-described, and a definitive health economic evaluation alongside a well-designed randomized control trial assessing probiotic prophylaxis has not been previously performed. This thesis consists of 3 separate manuscripts (with 2 published in peer-reviewed journals and 1 pending). The theme of this thesis was to: (1) describe the literature about the cost-effectiveness of probiotics in hospitalized patients in preventing healthcare-associated infections; (2) design a protocol for an economic evaluation alongside a randomized control trial (RCT) examining probiotic prophylaxis of VAP; and then (3) perform and analyze the health economic evaluation presented in the protocol. The first component of this thesis is a systematic review of probiotic prophylaxis of healthcare-associated infections in hospitalized patients. We performed an extensive search including multiple databases which found 7 studies. Probiotics demonstrated favourable cost-effectiveness in 6 of 7 (86%) economic evaluations, with 3 studies being manufacturer-supported, all suggesting cost-effectiveness. Certainty of cost-effectiveness evidence was very low due to risk of bias, imprecision and inconsistency using the GRADE approach. Hence further RCTs with economic evaluations were stated as a solution. The second component of this thesis is a study protocol for an economic evaluation alongside the Probiotics to Prevent Severe Pneumonia and Endotracheal Colonization Trial (PROSPECT), which assessed the efficacy of probiotic prophylaxis in the prevention of healthcare-associated infections (specifically VAP). The third component of this thesis is the cost-effectiveness analysis performed utilizing the individual patient data from PROSPECT to produce the economic evaluation (E-PROSPECT). As of the date of thesis submission, PROSPECT is still pending publication, and hence E-PROSPECT is also pending analysis and publication. However, I have prepared a draft manuscript (along with figures and tables) that will be produced at the conclusion of E-PROSPECT for thesis committee review. / Thesis / Master of Health Sciences (MSc) / Ventilator-associated pneumonia (VAP) is the most common healthcare-associated infection in the intensive care unit, resulting in a high burden of illness, mortality and increased cost. The literature around the cost-effectiveness of probiotics in prevention of health-care associated infections has not been previously well-described, and a definitive health economic evaluation alongside a well-designed randomized control trial assessing probiotic prophylaxis has not been previously performed. This thesis consists of 3 separate manuscripts (with 2 published in peer-reviewed journals and 1 pending). The theme of this thesis was to: (1) describe the literature about the cost-effectiveness of probiotics in hospitalized patients in preventing healthcare-associated infections; (2) design a protocol for an economic evaluation alongside a randomized control trial (RCT) examining probiotic prophylaxis of VAP; and then (3) perform and analyze the health economic evaluation presented in the protocol. The first component of this thesis is a systematic review of probiotic prophylaxis of healthcare-associated infections in hospitalized patients. We performed an extensive search including multiple databases which found 7 studies. Probiotics demonstrated favourable cost-effectiveness in 6 of 7 (86%) economic evaluations, with 3 studies being manufacturer-supported, all suggesting cost-effectiveness. Certainty of cost-effectiveness evidence was very low due to risk of bias, imprecision and inconsistency using the GRADE approach. Hence further RCTs with economic evaluations were stated as a solution. The second component of this thesis is a study protocol for an economic evaluation alongside the Probiotics to Prevent Severe Pneumonia and Endotracheal Colonization Trial (PROSPECT), which assessed the efficacy of probiotic prophylaxis in the prevention of healthcare-associated infections (specifically VAP). The third component of this thesis is the cost-effectiveness analysis performed utilizing the individual patient data from PROSPECT to produce the economic evaluation (E-PROSPECT). As of the date of thesis submission, PROSPECT is still pending publication, and hence E-PROSPECT is also pending analysis and publication. However, I have prepared a draft manuscript (along with figures and tables) that will be produced at the conclusion of E-PROSPECT for thesis committee review.