Tian L, Xu SS. Antibiotic-associated gut dysbiosis and intestinal failure in critically ill patients: Mechanisms and interventions. World J Gastroenterol 2026; 32(46): 123234 [DOI: 10.3748/wjg.123234]
Corresponding Author of This Article
Liang Tian, MD, Associate Faculty, Chief Pharmacist, Department of Pharmacy, Shanghai Deji Hospital, Qingdao University Shanghai Clinical Medical College, No. 378 Gulang Road, Putuo District, Shanghai 200331, China. tianliang@shneuro.org
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Critical Care Medicine
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review-article
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Tian L, Xu SS. Antibiotic-associated gut dysbiosis and intestinal failure in critically ill patients: Mechanisms and interventions. World J Gastroenterol 2026; 32(46): 123234 [DOI: 10.3748/wjg.123234]
World J Gastroenterol. Dec 14, 2026; 32(46): 123234 Published online Dec 14, 2026. doi: 10.3748/wjg.123234
Antibiotic-associated gut dysbiosis and intestinal failure in critically ill patients: Mechanisms and interventions
Liang Tian, Shan-Shan Xu
Liang Tian, Shan-Shan Xu, Department of Pharmacy, Shanghai Deji Hospital, Qingdao University Shanghai Clinical Medical College, Shanghai 200331, China
Author contributions: Tian L and Xu SS conceived and designed the study, analyzed the data and wrote the manuscript; Xu SS performed the systematic literature search and data extraction; Tian L supervised the study and critically revised the manuscript; and all authors have read and approved the final manuscript.
AI contribution statement: AI tools (specifically Claude, Anthropic, version claude-sonnet-4-6) were used solely for linguistic refinement, structural organization assistance, and formatting of the manuscript. No AI tool was involved in the generation of research data, interpretation of results, formulation of scientific conclusions, design of figures, or selection of references. All AI-generated outputs, including language suggestions and text organization, were critically reviewed, substantively revised, and verified for accuracy by the authors. The authors take full responsibility for the accuracy, originality, and integrity of the final manuscript in accordance with ICMJE and COPE guidelines.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Corresponding author: Liang Tian, MD, Associate Faculty, Chief Pharmacist, Department of Pharmacy, Shanghai Deji Hospital, Qingdao University Shanghai Clinical Medical College, No. 378 Gulang Road, Putuo District, Shanghai 200331, China. tianliang@shneuro.org
Received: May 13, 2026 Revised: June 30, 2026 Accepted: July 28, 2026 Published online: December 14, 2026 Processing time: 161 Days and 12.7 Hours
Abstract
Antibiotic-associated gut dysbiosis is an important and potentially modifiable driver of intestinal failure in critically ill patients. Critically ill patients in the intensive care unit receive antibiotics in 70%-90% of cases, yet 20%-50% develop acute gastrointestinal injury (AGI). The pathophysiological link between antibiotic exposure and organ failure remains incompletely synthesized. To systematically elucidate the molecular cascade linking antibiotic-induced gut dysbiosis to intestinal failure, and to map current evidence for stage-specific interventions in critically ill patients. PubMed, Web of Science, EMBASE, CNKI, and Wanfang databases were searched from inception to December 31, 2025. Eligible studies included original research, systematic reviews, randomized controlled trials, animal models, and clinical guidelines. Two investigators independently screened 3214 records; 40 studies were included. Antibiotic exposure initiates a four-stage cascade: (1) Gut microbiota dysbiosis - Shannon diversity declines 30%-50% within 7 days; (2) Short-chain fatty acid depletion - butyrate falls 50%-80%; (3) Intestinal barrier injury - tight junction proteins decline 20%-60%, permeability increases 2-3-fold; and (4) Systemic inflammation - plasma lipopolysaccharide rises 1.5-3-fold, activating Toll-like receptor 4/nuclear factor kappa B, driving systemic inflammatory response syndrome and multiple organ dysfunction syndrome. Antimicrobial stewardship programs reduce broad-spectrum antibiotic use by 20%-30% and AGI incidence by 15%-25%. Fecal microbiota transplantation achieves 80%-90% success for Clostridioides difficile-associated disease. Antibiotic-associated gut dysbiosis represents a mechanistically coherent, stage-specific, and clinically modifiable cascade driving intestinal failure in critically ill patients, with stage-targeted interventions offering measurable outcome benefits.
Core Tip: Broad-spectrum antibiotics precipitate a four-stage pathological cascade in critically ill patients: Gut microbiota dysbiosis, short-chain fatty acid depletion, intestinal barrier injury, and systemic inflammatory activation, ultimately driving multiple organ dysfunction syndrome. This review maps each cascade stage to a specific intervention, proposing a stage-based therapeutic framework. Three clinical priorities: Microbiome surveillance after prolonged antibiotic exposure, early enteral nutrition within 48 hours, and integration of days-of-therapy/antibiotic spectrum index metrics into stewardship decisions.
