Evaluation of Lactobacillus Coryniformis K8 Consumption by Health Care Workers Exposed to COVID-19 (LactoCor2 Project): Protocol for a Randomized Controlled Trial

P o ocol E alua ion o Lac obacillus Co yni o mis K8 Consump ion by Heal h Ca e Wo ke s Exposed o COVID-19 (Lac oCo 2 P ojec ): P o ocol o a Randomized Con olled T ial Raquel Rod íguez-Blanque1,2, PhD; Juan Ca los Sánchez-Ga cía1, PhD; Angel Cobos Va gas3, RN; M Soco o Ley a Ma ínez3, RN; Sil ia Ma ínez Diz3, PhD; Jona han Co és-Ma ín1, PhD; Ma ía Isabel To a -Gál ez1, PhD 1G upo de In es igación CTS-1068, Depa amen o de En e me ía, Facul ad de Ciencias de la Salud, Uni e sidad de G anada, G anada, Spain 2Hospi al Uni e si a io Clínico San Cecilio, G anada, Spain 3G upo de In es igación CTS-1068, Hospi al Uni e si a io Clínico San Cecilio, G anada, Spain Co esponding Au ho : Juan Ca los Sánchez-Ga cía, PhD G upo de In es igación CTS-1068 Depa amen o de En e me ía, Facul ad de Ciencias de la Salud, Uni e sidad de G anada A da. Ilus acion, 60 G anada, 18071 Spain Phone: 34 644322567 Email: jsanga @ug .es Abs ac Backg ound: Lac obacillus co yni o mis K8 CECT5711 has immune-modula ing p ope ies, enhances he immune esponse o i al an igens leading o he p oduc ion o speci ic an ibodies, and has an i-in lamma o y ac i i y, which may help o p e en uncon olled in lamma o y p ocesses leading o espi a o y and o he o gan ailu es. Objec i e: The pu pose o his s udy is o e alua e he e ec o he consump ion o a p obio ic s ain on he incidence and se e i y o COVID-19 in heal h pe sonnel who ca y ou hei p o essional wo k among pa ien s wi h in ec ion o suspec ed in ec ion by SARS-CoV-2. Me hods: This is a double-blind andomized clinical ial in which he expe imen al g oup will ecei e a capsule o L co yni o mis K8 pe day (3×109colony o me uni s/day), and he con ol g oup will ecei e a daily placebo capsule consis ing o mal odex in. A sample size o 314 olun ee s was calcula ed. Volun ee s mus mee he ollowing inclusion c i e ia: olde han 20 yea s and ac i e heal h pe sonnel ca ing o pa ien s wi h COVID-19, including all p o essionals such as medical doc o s, nu ses, and ca e ake s a he 2 e e al hospi als ha ea pa ien s wi h COVID-19. The main ou come o he clinical ial will be he incidence o symp oma ic in ec ion by SARS-CoV-2 in pe sonnel who ca e o pa ien s wi h suspec ed o con i med COVID-19. Resul s: The s udy had o be ex ended o he 2 e e al hospi als ha ea pa ien s wi h COVID-19 in he p o ince o G anada (Andalusia, Spain); Hospi al San Cecilio and Hospi al Vi gen de las Nie es. A o al o 255 indi iduals me he inclusion c i e ia and we e andomly assigned o one o he 2 g oups. Conclusions: The esul s o his andomized con olled ial will p o ide aluable in o ma ion ega ding he adminis a ion o L co yni o mis K8 agains COVID-19, including whe he he e a e ewe in ec ious p ocesses due o his i us o , in case o occu ence, whe he he disease is milde in pa icipan s aking he p obio ic s ain. T ial Regis a ion: ClinicalT ials.go NCT04366180; h p://www.clinical ials.go /c 2/show/NCT04366180 In e na ional Regis e ed Repo Iden i ie (IRRID): RR1-10.2196/37857 (JMIR Res P o oc 2023;12:e37857) doi: 10.2196/37857 KEYWORDS COVID-19; co ona i us; Lac obacillus; heal h ca e wo ke s; Lac obacilo; abajado es de la salud; SARS-CoV-2; p obió ico JMIR Res P o oc 2023 | ol. 12 | e37857 | p. 1h ps://www. esea chp o ocols.o g/2023/1/e37857 (page numbe no o ci a ion pu poses) Rod íguez-Blanque e alJMIR RESEARCH PROTOCOLS XSL • FO Rende X In oduc ion Humans ha e consumed lac ic bac e ia h oughou his o y, bu i was a he beginning o he 20 h cen u y when his consump ion was i s ela ed o bene icial p ope ies o heal h [1]. F om ha momen on, mul iple s udies bo h in i o and in i o ha e shown he bene icial e ec s ha he consump ion o his ype o bac e ia, called p obio ics, has on heal h. E ec s such as he imp o emen o in es inal unc ion [2,3], p e en ion o in es inal in ec ions [4], and immunomodula ion ha e been widely demons a ed [5]. In addi ion o hese bene icial e ec s, he consump ion o p obio ics has been ela ed o a educ ion in he incidence and se e i y o espi a o y in ec ions [4,6]. O al adminis a ion o lac ic acid bac e ia has been associa ed wi h an inc ease in inna e and acqui ed immune esponses [7,8]. The consump ion o ce ain s ains has been shown o induce an inc ease in IgA ela ed o he an i-in ec i e p ope ies o p obio ic bac e ia in dia hea [9,10]. Inna e immuni y is inc eased h ough an inc ease in he p opo ion and ac i i y o phagocy ic cells o he immune sys em, such as monocy es and neu ophils. The unc ion o na u al kille cells is also enhanced by he consump ion o p obio ic bac e ia [11]. Ac i a ion o he inna e immune sys em is essen ial, as i p oduces cy okines ha will lead o mo e specialized ac i a ion o he speci ic immune esponse. I has been sugges ed ha i is h ough his mechanism ha p obio ic bac e ia ac i a e he immune esponse, hus being able o unc ion as adju an s in accina ion p ocesses [12]. The Eu opean Food Sa e y Agency (EFSA) has published guidelines on how s udies should be conduc ed o demons a e he e ec o a p obio ic o na u al ing edien on he immune sys em. Among i s ecommenda ions is he use o accina ion p o ocols ha demons a e how he adminis a ion o he p obio ic ansla es in o an imp o emen in he esponse o an an igen [13]. Recen ly, a s udy ca ied ou a he Cen e Ins i u e o Food Science and Technology and Nu i ion o he Spanish Na ional Resea ch Council demons a ed ha he adminis a ion o Lac obacillus co yni o mis K8 CECT5711 inc eases he esponse o speci ic an ibodies agains hepa i is A in a accina ion p o ocol agains his i us [14]. In addi ion, a ce ain e ec on memo y T-helpe lymphocy es was obse ed, which inc eased in he p obio ic g oup wi h espec o baseline alues (mean 660, SD 223 cells/µL s mean 551, SD 213 cells/µL). These esul s highligh he po en ial o his p obio ic s ain o imp o e he immune esponse agains i al an igens. To e alua e his ac i i y ha boos s he immune esponse, ano he s udy was ca ied ou in an olde popula ion. This popula ion is mo e suscep ible o in ec ions due o he cha ac e is ic immunosenescence o age. A o al o 98 olde people esiding in nu sing homes pa icipa ed in his s udy. The olun ee s ecei ed a daily capsule o L co yni o mis K8 CECT5711 (3×109colony o me uni s/day) o 2 weeks p io o being accina ed agains he lu o a placebo. The pe cen age o se ocon e sion was highe in he g oup ecei ing he p obio ic han in he con ol g oup (93.1% s 72.7%; P=.04). Du ing he mon hs o Oc obe o Ap il, he olun ee s we e moni o ed, and he incidence o local symp oms associa ed wi h espi a o y in ec ions (so e h oa , cough, and nasal conges ion) was 48% lowe in he g oup ha ecei ed he p obio ic s ain han in he con ol g oup (P=.007). Fu he mo e, he consump ion o analgesics was signi ican ly educed in his g oup by 86% (P=.008) [15]. This la es s udy co obo a es he s ain’s abili y o imp o e he immune esponse agains i al an igens e en in he olde popula ion. We a e cu en ly expe iencing a pandemic due o COVID-19 ( he English ac onym o COVID-19), which s a ed in he Chinese ci y o Wuhan in Decembe 2019. Ha ing eached mo e han 100 e i o ies, he disease was decla ed a pandemic by he Wo ld Heal h O ganiza ion on Ma ch 11, 2020 [16]. The numbe o con i med cases con inued o g ow un il eaching 5,371,660 cases wo ldwide on May 22, 2020. In Spain, a he end o May 2020, despi e he con ainmen measu es ini ia ed in ea ly Ma ch, mo e han 235,772 cases we e egis e ed, and o hese pa ien s, mo e han 27,940 died [17]. The COVID-19 in ec ion p oduces lu-like symp oms, including e e , d y cough, dyspnea, myalgia, and a igue. In se e e cases, i is cha ac e ized by pneumonia, acu e espi a o y dis ess synd ome, and sep ic shock, which lead o dea h in app oxima ely 3% o hose in ec ed. T ansmission occu s h ough small d ople s ha a e emi ed when speaking, sneezing, o coughing by a ca ie and pass di ec ly o ano he pe son h ough inhala ion o by con ac wi h con amina ed objec s in he ecipien ’s nasal and ocula mucous memb anes. Symp oms s a a e app oxima ely 7-20 days o exposu e, and p e en ion a he popula ion le el consis s o equen hand washing, disin ec ing su aces wi h alcohol, and a oiding close con ac wi h o he people [15]. Some d ugs ha e been p oposed as an i i al ea men s, such as hyd oxychlo oquine, lopina i , i ona i , and o he s; se e e pneumonia is ea ed wi h b oad-spec um an ibio ics. The e is no up- o-da e, e ec i e ea men o he COVID-19 in ec ion. An a icle published in Ma ch 2020 shows how he immune esponse o he COVID-19 i us is simila o he esponse gene a ed by he in luenza i us [18]. Some au ho s p opose he use o p obio ics as a s a egy o mi iga e he e ec s o i uses [19]. Heal h ca e wo ke s (HCWs) a e a inc eased isk o COVID-19 in ec ion due o close con ac wi h highly in ec ious pa ien s as well as exposu e o undiagnosed o subclinical in ec ed cases. The s ess and physical exhaus ion associa ed wi h he pandemic may also impac he immune esponse o HCWs [20]. A ecen s udy examined 97 s udies and ound ha app oxima ely 11% o pa ien s wi h COVID-19 we e people wi h unde lying disease [21]. This ep esen ed a conside able pe cen age o all COVID-19 cases [22]. Al hough he numbe o se e e cases and mo ali y among HCWs was lowe han in o he popula ions [21], he numbe o COVID-19 cases has led o a sho age o HCWs, hus adding an ex a bu den o he igh agains his pandemic. I has been sugges ed by se e al au ho s ha p obio ics could play a ole in p e en ing and alle ia ing he se e i y o COVID-19 due o hei immune-modula ing, an i-in lamma o y, an ioxidan , and an i i al p ope ies [23-25]. The Loigolac obacillus co yni o misK8 CECT 5711 s ain has been JMIR Res P o oc 2023 | ol. 12 | e37857 | p. 2h ps://www. esea chp o ocols.o g/2023/1/e37857 (page numbe no o ci a ion pu poses) Rod íguez-Blanque e alJMIR RESEARCH PROTOCOLS XSL • FO Rende X shown o ha e he immune-modula ing capaci y in adul s [26] and child en [27,28]. Resea ch has shown ha his s ain causes an inc ease in hepa i is A i us an ibody le els a e o al adminis a ion in heal hy adul s as pa o hepa i is A accina ion [14]. A s udy in olde people ound ha he adminis a ion o L co yni o mis K8 s eng hened he immune esponse o in luenza accina ion and educed symp oms associa ed wi h espi a o y in ec ions [15]. A ecen andomized con olled ial conduc ed wi h nu sing home esiden s showed he bene i s o L co yni o mis K8 in he COVID-19 pandemic. This is because i may enhance he speci ic immune esponse ollowing COVID-19 in ec ion and also aid accine-speci ic esponses among he olde popula ion [29]. In his con ex , i is p oposed ha he immunomodula o y p ope ies o L co yni o mis K8 CECT5711 migh be use ul o COVID-19 managemen . Me hods Aim o he S udy The objec i e o his s udy is o e alua e he e ec s o he consump ion o L co yni o mis K8 on he incidence and se e i y o symp oma ic in ec ion by SARS-CoV-2 and he se e i y o COVID-19 in HCWs who ca y ou hei p o essional wo k among pa ien s wi h in ec ion o suspec ed in ec ion by SARS-CoV-2 a 2 e e al hospi als ha ea indi iduals wi h COVID-19 in he p o ince o G anada (Andalusia, Spain). Desc ip ion o T ea men s The adminis a ion o he expe imen al p oduc and he placebo will be ca ied ou in he o m o a gela in capsule ha will ha e he same weigh , consis ency, and colo . The Expe imen al G oup will ecei e ha d gela in capsules ha will con ain 3×109colony o ming uni s o Lco yni o mis K8 (120 mg), 10 mg magnesium s ea a e, and 120 mg mal odex in. The con ol g oup will ecei e ha d gela in capsules ha will con ain magnesium s ea a e (10 mg) and mal odex in (220 mg). Indi iduals om bo h g oups will ake 1 capsule a day (p e e ably wi h dinne ). Capsules o he p obio ic and placebo will be p o ided by Biosea ch Li e (G anada, Spain). S udy Design The s udy is a nu i ional, andomized, double-blind, con olled, and pa allel-g oup obse a ional p ospec i e coho s udy. Volun ee s will be dis ibu ed in o 2 g oups: a con ol g oup and an expe imen al g oup. The s udy will be pe o med as shown in Figu e 1. The ial has been egis e ed on ClinicalT ials.go (NCT04366180). Figu e 1. S udy lowcha . JMIR Res P o oc 2023 | ol. 12 | e37857 | p. 3h ps://www. esea chp o ocols.o g/2023/1/e37857 (page numbe no o ci a ion pu poses) Rod íguez-Blanque e alJMIR RESEARCH PROTOCOLS XSL • FO Rende X E hics App o al This clinical esea ch p o ocol has been p epa ed wi h ull unde s anding and in acco dance wi h he s anda ds o Good Clinical P ac ice in acco dance wi h CPMP/ICH/135/95, he Decla a ion o Helsinki (64 h Gene al Assembly, Fo aleza, B azil, Oc obe 2013), ISO 14155, and all ele an na ional guidelines. All in es iga o s pa icipa ing in he s udy a e app op ia ely quali ied. The p o ocol was app o ed by he Resea ch E hics Commi ee o he p o ince o G anada (3/2020_P_054; CEIM/CEI P o ince o G anada). Volun ee s will be included in he s udy a e in o med w i en consen is ob ained. Pa icipan s, In e en ion, and Ou comes Inclusion C i e ia The inclusion c i e ia included indi iduals olde han 18 yea s and ac i e HCWs, including all p o essional ca ego ies such as medicine, nu sing, and ca e aking, who a end cases classi ied as posi i e o suspicious o COVID-19 in he eme gency depa men , in ensi e ca e uni (ICU), o in he wa ds designa ed o ca e o such pa ien s; and he abili y o comple e he su eys and ha ing signed he in o med consen . Exclusion C i e ia The exclusion c i e ia excludes indi iduals wi h a posi i e es o COVID-19 con i med by polyme ase chain eac ion o se ology, indi iduals wi h concomi an pa hology such as HIV, ansplan a ion, ac i e cance , o o he ac i e immunosupp ession, and women who a e p egnan o in end o become p egnan in he subsequen mon hs. Rec ui men The ec ui men o pa icipan s will ake place a he San Cecilio Uni e si y Clinical Hospi al and a he Vi gen de las Nie es Uni e si y Hospi al in G anada among HCWs wi h high exposu e o pa ien s wi h COVID-19. Randomiza ion, Alloca ion, and Blinding Pa ien s will be andomly alloca ed o a con ol g oup o expe imen al g oup in a 1:1 a io by he block andomiza ion me hod wi h a block size o 4. Pa icipan s and in es iga o s will be blinded o he ea men alloca ion du ing he cou se o he in e en ion. The blind will be b oken a e s a is ical analysis is comple ed. Capsules o he con ol and expe imen al g oups will be p o ided in whi e con aine s labeled wi h a andom numbe . In e en ion Pa icipan s mee ing he inclusion c i e ia will be andomly assigned o he con ol o expe imen al g oup. Du ing he in e en ion, pa icipan s will be asked o inges a capsule pe day wi h some ood (p e e ably wi h dinne ). Follow-up isi s will be scheduled a he beginning, midpoin (1 mon h), and end o he in e en ion pe iod (2 mon hs). A he i s isi , baseline da a (age, sex, li es yle, medica ion, concomi an diseases, and cu en symp oms) will be collec ed. A ollow-up isi s, da a abou symp oms, medica ion, and ad e se e ec s will be eco ded (Table 1). Table 1. De ailed s udy p ocedu es. V4 (12 mon hs)V3 (W8)V2 (W4)V1 (W0)Visi s (V) pe week (W) ✓In o med consen o m ✓Inclusion o exclusion c i e ia ✓Randomiza ion o alloca ion ✓T ea men dis ibu ion ✓Basal da a ✓ ✓a ✓COVID-19 es ✓✓Symp oms ques ionnai e ✓✓✓Medica ion ques ionnai e ✓✓Ad e se e ec s ques ionnai e ✓Re u n o unconsumed capsules ✓E alua ion o he immune esponse o he accine aCOVID-19 es da a would be collec ed only i pe o med. Ou comes Measu es P ima y Ou comes The main ou come will be he incidence o symp oma ic SARS-CoV-2 in ec ion con i med by polyme ase chain eac ion o se ology in HCW ca ing o pa ien s wi h suspec ed o con i med COVID-19 a he San Cecilio Clinical Uni e si y Hospi al and a he Vi gen de las Nie es Uni e si y Hospi al. Seconda y Ou comes Incidence o hospi al admissions caused by SARS-CoV-2 in ec ion, he incidence o ICU admissions caused by SARS-CoV-2 in ec ion, he incidence o pneumonia caused by JMIR Res P o oc 2023 | ol. 12 | e37857 | p. 4h ps://www. esea chp o ocols.o g/2023/1/e37857 (page numbe no o ci a ion pu poses) Rod íguez-Blanque e alJMIR RESEARCH PROTOCOLS XSL • FO Rende X SARS-CoV-2 in ec ion, he incidence o he need o oxygen suppo , he incidence o gas oin es inal symp oms, days wi h a body empe a u e o >37.5 °C, days o pe sis en cough, days o pe sis en eeling o a igue, and use o pha macological ea men s. Da a o mild symp oms will be eco ded daily in he no ebook o he olun ee , and, in he case o hospi aliza ion, da a will be collec ed by in es iga o s om medical his o ies. In addi ion, he immune esponse and side e ec s o he COVID-19 accine in hese HCWs will be assessed. Da a will be collec ed on he accines ecei ed by he HCWs, including he name and ype o accine, doses ecei ed, da e o accina ion, and immune esponse o he HCWs. Wi hd awal, D opou , Discon inua ion, and Compliance Wi hd awal will be allowed a any ime du ing he ial. In es iga o s may ecommend discon inuing he ial i , in hei opinion, s aying in he s udy would be de imen al o he pa icipan ’s well-being. This decision mus be based on he appea ance o an ad e se e ec ha will be duly included in he case epo o m. Volun ee s will e u n he unconsumed capsules. Compliance ≤80% o he o al will be conside ed a iola ion o he p o ocol and will be conside ed d opou s. Ad e se E ec s L co yni o misspecies a e included in he Quali ied P esump ion o Sa e y lis published by he EFSA, which gua an ees sa e y o consump ion [30]. On each isi , i will be moni o ed o ad e se e ec s, which will be eco ded in he pa ien ’s medical his o y and e alua ed by he p incipal in es iga o . In he e en o se ious ad e se e en s conside ed ela ed o he expe imen al p oduc , he esea che will in o m he heal h au ho i ies and he Clinical Resea ch E hics Commi ee in ol ed in he clinical ial. Sample Size Gi en ha he cu en a es o in ec ion among heal h p o essionals wo ldwide a e e y di e en , he sample size has been based on he compa ison o 2 independen p opo ions o he use o he chi-squa e es . Fo an α o 5% and a powe o 80%, aking a pe cen age o a ec ed indi iduals in he con ol g oup o 15% and 10% as he minimum meaning ul di e ence o be de ec ed, a sample o 157 pe b anch would be necessa y, aking in o accoun a loss o 10% o pa icipan s. S a is ical Analysis Due o he u gency o he ci cums ances o he pandemic, he s a is ical me hods ha e no been ully planned. A s a is ical analysis plan will be p epa ed du ing he execu ion o he s udy and be o e he closu e o he da abase. The s a is ical me hods o be used, he s a egy o be ollowed in he case o missing alues, and he ables and igu es o include in he s a is ical epo will be desc ibed in de ail. The sample size has been calcula ed assuming 10% d opou s. I is no planned o eplace wi hd awal pa icipan s. In en ion- o- ea analysis will be ca ied ou , aking in o accoun all he da a o he ec ui ed olun ee s, e en i hey ha e no comple ed he in e en ion. In gene al, he da a will be p esen ed as absolu e equencies and pe cen ages in he case o quali a i e a iables. Fo he quan i a i e a iables, cen al endency s a is ics, such as he mean and median, and dispe sion s a is ics, such as he SD, IQR, minimum and maximum alues, and o indica e he shape o he dis ibu ion, shape measu es such as coe icien s o skewness and ku osis, will be used. In he case o o dinal a iables, depending on he numbe o ca ego ies, one o m o ano he o desc ip ion will be used. In all cases, a column ha includes he numbe o olun ee s wi h a ailable da a mus be added o he da a p esen a ion able. The analyses will be di ided by andomiza ion g oup. To analyze he compa isons be ween g oups, pa ame ic es s (S uden es o ANOVA) and nonpa ame ic es s (Mann-Whi ney Uo K uskal-Wallis) will be used o con inuous a iables acco ding o he cha ac e is ics o he s udy a iables (assump ion no mali y), while o ca ego ical a iables, chi-squa e es s o Fishe exac es s will be used. In he case o be ween- isi compa isons o con inuous a iables, pa ame ic es s (S uden es o pai ed da a o epea ed measu es ANOVA) and nonpa ame ic es s (Wilcoxon o F iedman) will be used, as app op ia e, acco ding o he cha ac e is ics o he s udy a iables (assump ion o no mali y) and he numbe o isi s o be compa ed, while he ca ego ical a iables will be compa ed using he McNema es . The e ec size will be es ima ed using CIs. The signi icance le el o he s a is ical es s used will be .05. All calcula ions will be pe o med wi h he SPSS s a is ical so wa e package ( e sion 26; IBM Co p). Fo he analysis o ad e se e en s, a desc ip i e analysis ( equencies and pe cen ages) will be ca ied ou h oughou he s udy, p esen ing a lis o he ad e se e en s g ouped acco ding o se e i y. These e en s will be lis ed by olun ee and andomiza ion g oups. Ad e se e en s and concomi an medica ion will be coded using a s anda diza ion sys em. In he case o ad e se e en s, he mos cu en e sion o he MedDRA sys em will be used, and o concomi an medica ion, he ATC code will be used. Da a Managemen To u he ensu e he accu acy and eliabili y o he collec ed da a, a ho ough p ocess o da a cleansing will be implemen ed be o e compu e iza ion a he coo dina ing cen e in G anada, Spain. Any e o s o inconsis encies iden i ied du ing his p ocess will be ec i ied o cla i ied wi h he ele an sou ce documen s o da abase manage s. The sou ce documen s and da abases will also be subjec ed o egula da a cleansing p ocedu es o main ain hei in eg i y h oughou he minimum 5-yea e en ion pe iod a e he s udy’s conclusion. Addi ionally, any pe sonal in o ma ion will be ca e ully sc eened and emo ed as pa o he da a cleansing p ocess o gua an ee anonymi y and con iden iali y. JMIR Res P o oc 2023 | ol. 12 | e37857 | p. 5h ps://www. esea chp o ocols.o g/2023/1/e37857 (page numbe no o ci a ion pu poses) Rod íguez-Blanque e alJMIR RESEARCH PROTOCOLS XSL • FO Rende X Dissemina ion Communica ions and scien i ic epo s ha eme ge om his s udy will be ca ied ou unde he esponsibili y o he p incipal in es iga o in ag eemen wi h he associa ed in es iga o s. Publica ion ules will ollow in e na ional ecommenda ions. The indings will also be sha ed wi h na ional heal h au ho i ies. Au ho ship will ollow he guidelines es ablished by he In e na ional Commi ee o Medical Jou nal Edi o s [31], which equi e subs an i e con ibu ions o he design, conduc , in e p e a ion, and epo ing o a ial. Resul s The s udy had o be ex ended o he 2 e e al hospi als ha ea COVID-19 cases in he p o ince o G anada (Andalusia, Spain), Hospi al San Cecilio and Hospi al Vi gen de las Nie es because he p ojec ed ec ui men was no su icien o he objec i e o he s udy and i was necessa y o expand he sample ob ained in o de o each as close as possible o he calcula ed sample. Finally, 255 olun ee s we e ec ui ed and andomly dis ibu ed in o 2 g oups: he con ol g oup (n=128) and he p obio ic g oup (n=127). In o de o measu e addi ional seconda y ou comes, he p ojec was kep open by collec ing da a ela ed o accines and immune esponses. The s udy s a ed in July 2020, wi h he i s pa o he s udy ending in Sep embe 2020. In o de o measu e addi ional seconda y ou comes, he p ojec was kep open by collec ing da a ela ed o accines and immune esponses un il Sep embe 2021. We will s a analyzing esponses in July 2023, wi h publica ion o esul s expec ed in he second hal o 2023. Discussion P incipal Findings This s udy is conduc ed o e alua e he e icacy o he e ec s o L co yni o misK8 consump ion on he incidence and se e i y o COVID-19 in HCWs wo king wi h SARS-CoV-2–in ec ed o suspec ed pa ien s in e e al hospi als o pa ien s wi h COVID-19 in he p o ince o G anada. This andomized con olled ial aims o s udy whe he he consump ion o L co yni o mis K8 will educe he incidence o SARS-CoV-2 in ec ion in he s a ca ing o pa ien s wi h suspec ed o con i med COVID-19 disease a he San Cecilio Uni e si y Hospi al and Vi gen de las Nie es Uni e si y Hospi al. Fo his pu pose, he incidence o hospi al admissions caused by SARS-CoV-2 in ec ion, bo h in he gene al hospi aliza ion a ea and in he ICU a ea, will be s udied in HCWs ca ing o SARS-CoV-2–in ec ed pa ien s. I is impo an o de e mine he p e alence o pneumonia caused by SARS-CoV-2 in ec ion and he need o oxygen supply o hese pa ien s. The p esence o e e will be s udied, and he numbe o days will be quan i ied, as well as he pe sis ence o cough and eeling o a igue. On he o he hand, i will also be assessed whe he hese wo ke s ha e needed pha macological ea men . This in e en ion aims o shed ligh on he use o p obio ics o enhance he immune e ec agains SARS-CoV-2. In addi ion, his in e en ion s udy aims o con ibu e o he unde s anding o he e ec o aking p obio ics o imp o e he immune esponse o accines agains SARS-CoV-2. An a icle published in Ma ch 2020 shows how he immune esponse o he COVID-19 i us is simila o he esponse gene a ed by he in luenza i us [18]. When he immune sys em wo ks p ope ly, he i s ba ie o SARS-CoV-2 is he inna e esponse. This inna e esponse, cha ac e ized by in e e on and cy okines, which a e small p o eins esponsible o symp oms such as e e , headaches, and muscle pain, has 2 unc ions: o slow down he eplica ion and sp ead o he i us un il he speci ic immune esponse (which, when i is a i us ha has no been p e iously con ac ed, akes app oxima ely 2 o 3 weeks) is ac i a ed. The speci ic immune esponse is wha will s op and ul ima ely elimina e he in ec ion. This speci ic esponse also con ols he inna e esponse in o de o p e en excessi e ac i i y om damaging he issues. When his esponse wo ks in a co ec and coo dina ed manne , he in ec ion is o e come, showing symp oms mo e o less simila o hose o he lu. Howe e , in an olde popula ion expe iencing dys unc ion o he age- ela ed immune esponse, called immunosenescence, o in a popula ion in which he esponse appea s o be poo ly coo dina ed, he inna e esponse occu s la e o is ine ec i e, gi ing he i us ime o eplica e and sp ead and delaying he ac i a ion o he speci ic esponse. Be o e he massi e in asion o issues, he inna e esponse exagge a edly damages issues, causing espi a o y ailu e and ailu e in o he o gans, such as he kidney. Gi en his si ua ion, some au ho s speak o 3 disease s a es ha equi e di e en app oaches: an asymp oma ic s a e, a second s a e wi h nonse e e symp oms, and a hi d s a e wi h se e e espi a o y symp oms and a high i al load. Du ing he i s 2 s a es, a speci ic immune esponse is equi ed o elimina e he i us and p e en he disease om p og essing o s a e 3. In his phase, s a egies o enhance he immune esponse a e impo an . Howe e , in s a e 3, when he immune sys em has ailed and he i us has sp ead, he damage o he issues causes a massi e in lamma o y esponse; he s a egy should be aimed a con olling ha in lamma ion [27]. Se e al clinical ials ha e e idenced he posi i e e ec s o ce ain p obio ic s ains on he p e en ion o espi a o y ac in ec ions. In ac , some au ho s p opose he use o p obio ics as a s a egy o mi iga e he e ec s o SARS-CoV-2 [19]. Mechanisms ha would be in ol ed in a posi i e e ec o p obio ic ea men s on espi a o y i uses include enhancemen o he in es inal epi helial ba ie , compe i ion wi h pa hogens o nu ien s and adhesion o he in es inal epi helium, p oduc ion o an imic obial subs ances, and modula ion o he hos immune sys em [19]. L co yni o mis K8 CECT5711 has immunomodula o y p ope ies ha could be use ul o COVID-19 managemen . On he one hand, we ha e p e iously discussed i s abili y o imp o e he immune esponse agains i al an igens, leading o he p oduc ion o speci ic an ibodies [14,15]. On he o he hand, he s ain has been shown in animal expe imen s o ha e an i-in lamma o y capaci y in models o in lamma ion [3,27]. This an i-in lamma o y ac i i y would also be o in e es in he case o COVID-19, as i could help p e en uncon olled in lamma o y p ocesses om leading o espi a o y and o he o gan ailu e. JMIR Res P o oc 2023 | ol. 12 | e37857 | p. 6h ps://www. esea chp o ocols.o g/2023/1/e37857 (page numbe no o ci a ion pu poses) Rod íguez-Blanque e alJMIR RESEARCH PROTOCOLS XSL • FO Rende X The wo king hypo hesis is ha he adminis a ion o L co yni o mis K8 will s imula e he immune esponse o people exposed o COVID-19, ac ing as an adju an ha con ibu es o de eloping an e ec i e esponse agains he i us, and he e o e ewe in ec ious cases a e p esen ed due o his i us o , in he e en o an occu ence, he disease is milde among he pa icipan s aking he p obio ic s ain. The high deg ee o exposu e among HCWs pu s hem a high isk o con ac ing he i us. I we add o his si ua ion he ac ha he s ess and physical o e exe ion caused by he pandemic can a ec he immune esponse, he isk inc eases e en mo e. The s udy has been designed o demons a e i he consump ion o hese p obio ic bac e ia migh con ibu e o educing he le el o incidence, o a leas he se e i y o in ec ion, in his popula ion. Conclusions Fu he knowledge in his a ea could lead o an imp o emen in he immune esponse o HCWs o nonin ec ion wi h SARS-CoV-2 o o a educ ion o symp oms in cases o in ec ion. This would ensu e ha HCW wo k o ces a e no impai ed in hei abili y o cope wi h SARS-CoV-2 and ha hose in ec ed wi h SARS-CoV-2 a e able o e u n o wo k mo e quickly han hose who do no ake p obio ic supplemen s. Acknowledgmen s We hank all pa icipan s o hei aluable con ibu ions. We would especially like o hank he managing di ec o s o he San Cecilio and Vi gen de las Nie es Uni e si y Hospi als. Da a A ailabili y The da a se s gene a ed du ing his s udy a e a ailable om he co esponding au ho upon easonable eques . Au ho s' Con ibu ions All au ho s pa icipa ed in he w i ing and eading o he manusc ip and app o ed he inal e sion. Con lic s o In e es None decla ed. Re e ences 1. Me chniko E. The P olonga ion o Li e: Op imis ic S udies. London: William Heinemann; 1907. 2. Dida i T, Moza a i S, Nik a S, Abdollahi M. E ec i eness o p obio ics in i i able bowel synd ome: Upda ed sys ema ic e iew wi h me a-analysis. Wo ld J Gas oen e ol 2015 Ma 14;21(10):3072-3084 [FREE Full ex ] [doi: 10.3748/wjg. 21.i10.3072] [Medline: 25780308] 3. Oli a es M, Díaz-Rope o MAP, Gómez N, La a-Villoslada F, Sie a S, Maldonado JA, e al. O al adminis a ion o wo p obio ic s ains, Lac obacillus gasse i CECT5714 and Lac obacillus co yni o mis CECT5711, enhances he in es inal unc ion o heal hy adul s. In J Food Mic obiol 2006 Ma 15;107(2):104-111 [doi: 10.1016/j.ij oodmic o.2005.08.019] [Medline: 16271414] 4. Maldonado J, Cañaba e F, Sempe e L, Vela F, Sánchez AR, Na bona E, e al. Human milk p obio ic Lac obacillus e men um CECT5716 educes he incidence o gas oin es inal and uppe espi a o y ac in ec ions in in an s. J Pedia Gas oen e ol Nu 2012 Jan;54(1):55-61 [FREE Full ex ] [doi: 10.1097/MPG.0b013e3182333 18] [Medline: 21873895] 5. F ei R, Akdis M, O'Mahony L. P ebio ics, p obio ics, synbio ics, and he immune sys em: expe imen al da a and clinical e idence. Cu Opin Gas oen e ol 2015 Ma ;31(2):153-158 [FREE Full ex ] [doi: 10.1097/MOG.0000000000000151] [Medline: 25594887] 6. Dumas A, Be na d L, Poque Y, Lugo-Villa ino G, Ney olles O. The ole o he lung mic obio a and he gu -lung axis in espi a o y in ec ious diseases. Cell Mic obiol 2018 Dec;20(12):e12966 [FREE Full ex ] [doi: 10.1111/cmi.12966] [Medline: 30329198] 7. Schi in EJ, Rocha FR, Link-Ams e H, Aeschlimann JM, Donne -Hughes A. Immunomodula ion o human blood cells ollowing he inges ion o lac ic acid bac e ia. J Dai y Sci 1995 Ma ;78(3):491-497 [FREE Full ex ] [doi: 10.3168/jds.S0022-0302(95)76659-0] [Medline: 7782506] 8. Isolau i E, Sü as Y, Kankaanpää P, A ilommi H, Salminen S. P obio ics: e ec s on immuni y. Am J Clin Nu 2001 Feb;73(2 Suppl):444S-450S [FREE Full ex ] [doi: 10.1093/ajcn/73.2.444s] [Medline: 11157355] 9. Kaila M, Isolau i E, Soppi E, Vi anen E, Laine S, A ilommi H. Enhancemen o he ci cula ing an ibody sec e ing cell esponse in human dia hea by a human Lac obacillus s ain. Pedia Res 1992 Aug;32(2):141-144 [doi: 10.1203/00006450-199208000-00002] [Medline: 1324462] 10. Majamaa H, Isolau i E, Saxelin M, Vesika i T. Lac ic acid bac e ia in he ea men o acu e o a i us gas oen e i is. J Pedia Gas oen e ol Nu 1995 Ap ;20(3):333-338 [doi: 10.1097/00005176-199504000-00012] [Medline: 7608829] JMIR Res P o oc 2023 | ol. 12 | e37857 | p. 7h ps://www. esea chp o ocols.o g/2023/1/e37857 (page numbe no o ci a ion pu poses) Rod íguez-Blanque e alJMIR RESEARCH PROTOCOLS XSL • FO Rende X 11. Nagao F, Nakayama M, Mu o T, Okumu a K. E ec s o a e men ed milk d ink con aining Lac obacillus casei s ain Shi o a on he immune sys em in heal hy human subjec s. Biosci Bio echnol Biochem 2000;64(12):2706-2708 [FREE Full ex ] [doi: 10.1271/bbb.64.2706] [Medline: 11210142] 12. Oli a es M, Díaz-Rope o MP, Sie a S, La a-Villoslada F, Fonollá J, Na as M, e al. O al in ake o Lac obacillus e men um CECT5716 enhances he e ec s o in luenza accina ion. Nu i ion 2007 Ma ;23(3):254-260 [doi: 10.1016/j.nu .2007.01.004] [Medline: 17352961] 13. EFSA Panel on Biological Haza ds (BIOHAZ), Ricci A, Allende A, Bol on D, Chemaly M, Da ies R, e al. Upda e o he lis o QPS- ecommended biological agen s in en ionally added o ood o eed as no i ied o EFSA 7: sui abili y o axonomic uni s no i ied o EFSA un il Sep embe 2017. EFSA J 2018 Jan;16(1):e05131 [FREE Full ex ] [doi: 10.2903/j.e sa.2018.5131] [Medline: 32625678] 14. Redondo N, No a E, Gheo ghe A, Díaz LE, He nández A, Ma cos A. E alua ion o CECT5711 s ain as a coadju an in a accina ion p ocess: a andomised clinical ial in heal hy adul s. Nu Me ab (Lond) 2017;14:2 [FREE Full ex ] [doi: 10.1186/s12986-016-0154-2] [Medline: 28070204] 15. Fonollá J, G acián C, Maldonado-Lobón JA, Rome o C, Bédma A, Ca illo JC, e al. E ec s o Lac obacillus co yni o mis K8 CECT5711 on he immune esponse o in luenza accina ion and he assessmen o common espi a o y symp oms in elde ly subjec s: a andomized con olled ial. Eu J Nu 2019 Feb;58(1):83-90 [FREE Full ex ] [doi: 10.1007/s00394-017-1573-1] [Medline: 29124387] 16. WHO Di ec o -Gene al's opening ema ks a he media b ie ing on COVID-19 - 11 Ma ch 2020. Wo ld Heal h O ganiza ion. URL: h ps://www.who.in /di ec o -gene al/speeches/de ail/ who-di ec o -gene al-s-opening- ema ks-a - he-media-b ie ing-on-co id-19---11-ma ch-2020 [accessed 2023-03-05] 17. Gobie no de España Minis e io de Sanidad - P o esionales. En e medad po nue o co ona i us, COVID-19. Minis e io de Sanidad. URL: h ps://www.sanidad.gob.es/p o esionales/saludPublica/ccayes/ale asAc ual/nCo /home.h m [accessed 2023-03-05] 18. The a ajan I, Nguyen THO, Kou sakos M, D uce J, Caly L, an de Sand CE, e al. B ead h o concomi an immune esponses p io o pa ien eco e y: a case epo o non-se e e COVID-19. Na Med 2020 Ap ;26(4):453-455 [FREE Full ex ] [doi: 10.1038/s41591-020-0819-2] [Medline: 32284614] 19. Baud D, Dimopoulou Ag i V, Gibson GR, Reid G, Giannoni E. Using P obio ics o Fla en he Cu e o Co ona i us Disease COVID-2019 Pandemic. F on Public Heal h 2020;8:186 [FREE Full ex ] [doi: 10.3389/ pubh.2020.00186] [Medline: 32574290] 20. Sege s om SC, Mille GE. Psychological s ess and he human immune sys em: a me a-analy ic s udy o 30 yea s o inqui y. Psychol Bull 2004 Jul;130(4):601-630 [FREE Full ex ] [doi: 10.1037/0033-2909.130.4.601] [Medline: 15250815] 21. Gómez-Ochoa SA, F anco OH, Rojas LZ, Raguindin PF, Roa-Díaz ZM, Wyssmann BM, e al. COVID-19 in heal h-ca e wo ke s: a li ing sys ema ic e iew and me a-analysis o p e alence, isk ac o s, clinical cha ac e is ics, and ou comes. Am J Epidemiol 2021 Jan 04;190(1):161-175 [FREE Full ex ] [doi: 10.1093/aje/kwaa191] [Medline: 32870978] 22. Sahu AK, Am i hanand VT, Ma hew R, Agga wal P, Naye J, Bhoi S. COVID-19 in heal h ca e wo ke s - A sys ema ic e iew and me a-analysis. Am J Eme g Med 2020 Sep;38(9):1727-1731 [FREE Full ex ] [doi: 10.1016/j.ajem.2020.05.113] [Medline: 32738467] 23. Ku ian SJ, Unnik ishnan MK, Mi aj SS, Bagchi D, Bane jee M, Reddy BS, e al. P obio ics in p e en ion and ea men o COVID-19: cu en pe spec i e and u u e p ospec s. A ch Med Res 2021 Aug;52(6):582-594 [FREE Full ex ] [doi: 10.1016/j.a cmed.2021.03.002] [Medline: 33785208] 24. Singh K, Rao A. P obio ics: A po en ial immunomodula o in COVID-19 in ec ion managemen . Nu Res 2021 Ma ;87:1-12 [FREE Full ex ] [doi: 10.1016/j.nu es.2020.12.014] [Medline: 33592454] 25. Mahoo i M, Mi i SM, Abdolalipou E, Ghaemi A. The immunomodula o y e ec s o p obio ics on espi a o y i al in ec ions: A hin o COVID-19 ea men ? Mic ob Pa hog 2020 No ;148:104452 [FREE Full ex ] [doi: 10.1016/j.micpa h.2020.104452] [Medline: 32818576] 26. Oli a es M, Díaz-Rope o MP, Gómez N, La a-Villoslada F, Sie a S, Maldonado JA, e al. The consump ion o wo new p obio ic s ains, Lac obacillus gasse i CECT 5714 and Lac obacillus co yni o mis CECT 5711, boos s he immune sys em o heal hy humans. In Mic obiol 2006;9(1):47-52 [Medline: 16636989] 27. La a-Villoslada F, Sie a S, Ma ín R, Delgado S, Rod íguez JM, Oli a es M, e al. Sa e y assessmen o wo p obio ic s ains, Lac obacillus co yni o mis CECT5711 and Lac obacillus gasse i CECT5714. J Appl Mic obiol 2007 Jul;103(1):175-184 [FREE Full ex ] [doi: 10.1111/j.1365-2672.2006.03225.x] [Medline: 17584463] 28. Ma ínez-Caña a e A, Sie a S, La a-Villoslada F, Rome o J, Maldonado J, Boza J, e al. A p obio ic dai y p oduc con aining L. gasse i CECT5714 and L. co yni o mis CECT5711 induces immunological changes in child en su e ing om alle gy. Pedia Alle gy Immunol 2009 Sep;20(6):592-600 [doi: 10.1111/j.1399-3038.2008.00833.x] [Medline: 19594864] 29. Fe nández-Fe ei o A, Fo migo-Coucei o FJ, Veiga-Gu ie ez R, Maldonado-Lobón JA, He mida-Cao AM, Rod iguez C, e al. E ec s o K8 CECT 5711 on he immune esponse o elde ly subjec s o COVID-19 accina ion: a andomized con olled ial. Nu ien s 2022 Jan 05;14(1):228 [FREE Full ex ] [doi: 10.3390/nu14010228] [Medline: 35011103] 30. Shi Y, Wang Y, Shao C, Huang J, Gan J, Huang X, e al. COVID-19 in ec ion: he pe spec i es on immune esponses. Cell Dea h Di e 2020 May;27(5):1451-1454 [FREE Full ex ] [doi: 10.1038/s41418-020-0530-3] [Medline: 32205856] JMIR Res P o oc 2023 | ol. 12 | e37857 | p. 8h ps://www. esea chp o ocols.o g/2023/1/e37857 (page numbe no o ci a ion pu poses) Rod íguez-Blanque e alJMIR RESEARCH PROTOCOLS XSL • FO Rende X 31. In e na ional Commi ee o Medical Jou nal Edi o s. URL: h ps://www.icmje.o g/ [accessed 2023-06-10] Abb e ia ions EFSA: Eu opean Food Sa e y Agency HCW: heal h ca e wo ke ICU: in ensi e ca e uni Edi ed by T Leung; submi ed 09.03.22; pee - e iewed by D Pucia o, YL Leung; commen s o au ho 05.03.23; e ised e sion ecei ed 07.03.23; accep ed 12.04.23; published 28.06.23 Please ci e as: Rod íguez-Blanque R, Sánchez-Ga cía JC, Cobos Va gas A, Ley a Ma ínez MS, Ma ínez Diz S, Co és-Ma ín J, To a -Gál ez MI E alua ion o Lac obacillus Co yni o mis K8 Consump ion by Heal h Ca e Wo ke s Exposed o COVID-19 (Lac oCo 2 P ojec ): P o ocol o a Randomized Con olled T ial JMIR Res P o oc 2023;12:e37857 URL: h ps://www. esea chp o ocols.o g/2023/1/e37857 doi: 10.2196/37857 PMID: 37285326 ©Raquel Rod íguez-Blanque, Juan Ca los Sánchez-Ga cía, Angel Cobos Va gas, M Soco o Ley a Ma ínez, Sil ia Ma ínez Diz, Jona han Co és-Ma ín, Ma ía Isabel To a -Gál ez. O iginally published in JMIR Resea ch P o ocols (h ps://www. esea chp o ocols.o g), 28.06.2023. This is an open-access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion License (h ps://c ea i ecommons.o g/licenses/by/4.0/), which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k, i s published in JMIR Resea ch P o ocols, is p ope ly ci ed. The comple e bibliog aphic in o ma ion, a link o he o iginal publica ion on h ps://www. esea chp o ocols.o g, as well as his copy igh and license in o ma ion mus be included. JMIR Res P o oc 2023 | ol. 12 | e37857 | p. 9h ps://www. esea chp o ocols.o g/2023/1/e37857 (page numbe no o ci a ion pu poses) Rod íguez-Blanque e alJMIR RESEARCH PROTOCOLS XSL • FO Rende X