Most of us at some point in our lives had to have some sort of antibiotics. Statistically, each of us receives 10-20 antibiotic treatments by age of 18. That’s the average number and very often it’s actually more than that. Before the era of antibiotics the average life expectancy was 63 years, now it’s 78. It is a good thing, right? Antibiotics are saving lives and letting us enjoy life longer. However, assumption that they are safe to use led to microbial resistance to antibiotic treatments. Moreover, we know that antibiotics kill not only bad bacteria, but also good ones1. And a number of studies showed that too often our microbiota cannot fully recover after antibiotic treatment2. This means that each new generation receives less bacteria at birth (especially those born via C-section) than the previous one. Is it good or bad? We don’t know yet. What we know is that overuse of antibiotics at infancy and early childhood may lead to allergies, asthma, Candida infection, type 1 diabetes, irritable bowel disease, celiac disease, rheumatoid arthritis, gastroenteritis, obesity and colorectal cancer3,4. How probiotics can help?
What actions should be taken? First, better assessment which patients and in particular pregnant women need antibiotics. Second, developing narrow-spectrum antimicrobial agents (like bacteriocins) to minimize collateral damage. Third, effective probiotics should be used to stabilize microbial population in the gut.
What is antibiotic associated diarrhea?
So going back to the topic what antibiotic-associated diarrhea (AAD) is? It is referred to as unexplained diarrhea that occurs in association with antibiotic administration. Antibiotic-associated diarrhea is not uncommon. It occurs in 25%-30% of patients receiving antibiotics, and is more common with amoxicillin/clavulanic acid antibiotics (Augmentin®).
What are probiotics?
Probiotics are good bacteria that when ingested provide us with beneficial health effects such as stimulation of immune system, protecting us from pathogenic or bad bacteria and helping to digest food that our bodies cannot digest. They also help stabilizing our healthy intestinal microbial community.
Which probiotic strains have been clinically found to be beneficial with AAD?
- Lactobacillus rhamnosus GG 5,6 (LGG) is one of the most studied probiotic strains. At least twelve different placebo-controlled trials have been performed in children and adults in order to evaluate effectiveness of this bacterium in AAD. Treatment with LGG was effective in all of them. LGG strain can be found in Culturelle and Ethical Nutrients.
- Saccharomyces boulardii7 also provides clinically significant benefit in the treatment of ADD and acute infection. Not only it shortens the duration of diarrhea compared to the controlled groups but in many cases is also reduces hospital stay. S. boulardii can be found in Jarrow formulas® and highly recommended clinically proven strain found in Florastor.
- Lactobacillus helveticus R00528 and Lactobacillus rhamnosus R00118 have been given daily to adults undergoing amoxicillin/clavulanic acid (Augmentin®) treatment in a very recent randomized, double-blind, placebo-controlled study (the best type of a clinical trial) and showed significant reduction in diarrhoea. L. helveticus R0052 can be found in Garden of Life and L. rhamnosus R0011 can be found in Jarrow formulas®.
- Lactobacillus reuteri ATCC 55730 (DSM 17938)9 has been shown to be very effective in reducing AAD in adults and acute diarrhea in kids10. This strain has also been demonstrated to improve colic symptoms in infants and reduce crying times in breastfed infants11. L. reuteri ATCC 55730 can be found in Biogaia and Gerber.
- Bifidobacterium lactis Bb-1212 improved diarrhea in formula-fed infants attending child care centers by reducing the number and making the episode shorter. B. lactic Bb-12 can be found in TruBiotics®.
What’s the verdict?
Are there any studies that contradict the claim that probiotics are effective in preventing AAD. There are some controversial studies like this one, which is the largest randomized, double-blind, placebo-controlled trial to date13. This study used a mixture of bifidobacterial and lactobacilli strains (two Lactobacillus acidophilus strains CUL60 [NCIMB 30157] and CUL21 [NCIMB 30156], Bifidobacterium bifidum CUL20 [NCIMB 30153] and Bifidobacterium lactis CUL34 [NCIMB 30172]) in 1493 randomly assigned patients and identified no evidence that this particular formulation was effective in prevention of AAD.
It’s important to remember, however, that different microbial strains (strain designation underlined: Lactobacillus rhamnosus GG vs. Lactobacillus rhamnosus JB-1) within the same species (species: Lactobacillus rhamnosus) can have totally different probiotic properties. In fact, one of them may have probiotic properties and another one may not. Therefore it is important to do your research before choosing the right probiotic product.
To sum it up, there is enough scientific evidence demonstrating that particular strains of probiotic bacteria (especially those listed above) have beneficial effects in reducing antibiotic associated diarrhea.
You might also like to read the articles about:
- Blaser M. Antibiotic overuse: Stop the killing of beneficial bacteria. Nature. 2011;476(7361):393-394.
- Reid G, Younes J, Van der Mei H, Gloor G, Knight R, Busscher H. Microbiota restoration: natural and supplemented recovery of human microbial communities. Nature Reviews Microbiology. 2010;9(1):27-38.
- Botero Palacio L, Delgado Serrano L, Cepeda Hernández M, Del Portillo Obando P, Zambrano Eder M. THE HUMAN MICROBIOTA: THE ROLE OF MICROBIAL COMMUNITIES IN HEALTH AND DISEASE. Acta Biológica Colombiana. 2015;21(1).
- Langdon A, Crook N, Dantas G. The effects of antibiotics on the microbiome throughout development and alternative approaches for therapeutic modulation. Genome Medicine. 2016;8(1).
- Teran C, Teran-Escalera C, Villarroel P. Nitazoxanide vs. probiotics for the treatment of acute rotavirus diarrhea in children: a randomized, single-blind, controlled trial in Bolivian children. International Journal of Infectious Diseases. 2009;13(4):518-523.
- Szajewska HKołodziej M. Systematic review with meta-analysis: Lactobacillus rhamnosus GG in the prevention of antibiotic-associated diarrhoea in children and adults. Alimentary Pharmacology & Therapeutics. 2015;42(10):1149-1157.
- Dinleyici E, Eren M, Ozen M, Yargic Z, Vandenplas Y. Effectiveness and safety of Saccharomyces boulardii for acute infectious diarrhea. Expert Opinion on Biological Therapy. 2012;12(4):395-410.
- Evans M, Salewski R, Christman M, Girard S, Tompkins T. Effectiveness of Lactobacillus helveticus and Lactobacillus rhamnosus for the management of antibiotic-associated diarrhoea in healthy adults: a randomised, double-blind, placebo-controlled trial. British Journal of Nutrition. 2016;116(01):94-103.
- Cimperman L, Bayless G, Best K, Diligente A, Mordarski B, Oster M et al. A Randomized, Double-blind, Placebo-controlled Pilot Study of Lactobacillus reuteri ATCC 55730 for the Prevention of Antibiotic-associated Diarrhea in Hospitalized Adults. Journal of Clinical Gastroenterology. 2011;45(9):785-789.
- Francavilla R, Lionetti E, Castellaneta S, Ciruzzi F, Indrio F, Masciale A et al. Randomised clinical trial: Lactobacillus reuteri DSM 17938 vs. placebo in children with acute diarrhoea – a double-blind study. Alimentary Pharmacology & Therapeutics. 2012;36(4):363-369.
- Chau K, Lau E, Greenberg S, Jacobson S, Yazdani-Brojeni P, Verma N et al. Probiotics for Infantile Colic: A Randomized, Double-Blind, Placebo-Controlled Trial Investigating Lactobacillus reuteri DSM 17938. The Journal of Pediatrics. 2015;166(1):74-78.e1.
- Weizman Z, Asli G, Alsheikh A. Effect of a probiotic infant formula on infections in child care centers: comparison of two probiotic agents. Pediatrics. 2005;115(1):5-9.
- Allen S, Wareham K, Wang D, Bradley C, Hutchings H, Harris W et al. Lactobacilli and bifidobacteria in the prevention of antibiotic-associated diarrhoea and Clostridium difficile diarrhoea in older inpatients (PLACIDE): a randomised, double-blind, placebo-controlled, multicentre trial. The Lancet. 2013;382(9900):1249-1257.
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