Intervention
Probiotics in adults and children taking antibiotics.
There is some evidence that the benefits of probiotics are strain specific. Lactobacillus rhamnosus GG and Saccharomyces boulardii appear to be the most efficacious choice for preventing antibiotic-associated diarrhoea (AAD), while Lactobacillus casei may be the best for specifically preventing severe C. difficile-related diarrhoea.
Introduction
AAD occurs in 2–15% of people taking antibiotics. Some 20–30% of cases are thought to be caused by Clostridium difficile infection.
Indication
To reduce risk of AAD.
While any antibiotic may cause diarrhoea, higher rates of diarrhea have been associated with amoxycillin-clavulanate, cephalosporins and clindamycin.
Longer duration of antibiotic use (>3 days) is more likely to cause AAD.
Children aged <2 years and people who are frail or with co-morbid conditions may have a higher risk of AAD than the general population.
Note: This evidence review did not cover probiotic use for the treatment of established AAD. However, given its efficacy in prevention, the use of probiotics in established AAD would be reasonable.
Precautions
The short-term use of probiotics appears to be safe at least in non-immunocompromised people.
Availability
Many different formulations of probiotics (capsules, powders, sachets) are available from supermarkets, pharmacies and health food stores. Products containing probiotics classified as foodstuffs (e.g. yoghurt) are not subjected to the same requirements to establish the amount of active ingredient as those marketed as complementary medicines.
The following non exhaustive list shows products available in Australia that have sufficient microbes (colony forming units CFU) of the right strains:
|
Product
|
Microbes
B=billion
|
Indicative price
|
|
Blackmores Probiotics +
|
5 strains, 20B total
|
$48 for 90 at Chemist
|
|
Elevit
|
L.rhamnosus 2.8B plus others 8B total
|
$31 for 30 at Chemist
|
|
Life-Space Broad spectrum probiotic
|
32 B cfu, including several strains L.rhamnosus
|
$18 for 40 at supermarket or Chemist
|
|
Inner Health capsules. (not gummies)
|
All contain L.rhamnosus, > 5 B cfu some contain extra species.
|
$33 for 30 at supermarket or chemist.
|
|
Natures Way restore probiotic 30 billion
|
L.rhamnosus 25 B cfu
|
$14 for 30 at supermarket.
|
|
Bioceuticals SB Floractiv
|
Saccharomyces cerevisiae (Boulardii) 250mg (5 B CFU)
|
$28 for 30 at chemist
|
|
Henry Blooms
|
Saccharomyces cerevisiae (Boulardii) 250mg (5 B CFU)
|
$25 for 60 at chemist
|
Description
Probiotics are live organisms thought to improve the microbial balance of the host. They are thought to reduce the risks of changes in gut flora related to antibiotic use and colonisation by pathogenic bacteria. As they are effective when administered concurrently with antibiotics that probably kill the probiotic organisms, they may work via a different mechanism.
Probiotics have been shown to reduce AAD in adults and children, in hospitalized and ambulatory patient settings, with different probiotic species, with lower or higher doses of probiotics and in studies at high or low risks of bias.
Whilst a range of probiotic species have shown positive results in trials, the best results were for preparations containing Lactobacillus rhamnosus or Saccharomyces boulardii at 5 to 40 billion CFU per day. In children the NNT was 6. Lower dose preparations with less than 5 billion CFU were also effective, with NNT=9.
Six of the trials were conducted in children less than 24 months old, and it was safe and effective in these groups.
Probiotic use is a low-risk, low-cost useful intervention for people at a higher risk of AAD.
Tips and challenges
- Probiotics can be taken during and/or after antibiotic dosing. However, probiotic use for the minimum of the antibiotic treatment duration would be reasonable.
- While there are plenty of high dose Lactobacillus rhamnosus preparations and a few Saccharomyces boulardii preparations available in Australia in capsules, the available infant drops are very low dose. Capsule products can be opened and sprinkled on food.
- The research into the use of probiotics is complex as nearly every study uses a different mixture of species and strains of microbes. It is unclear if beneficial effects are from one or all the components of the preparations used. In subgroup analyses there was similar effectiveness of single strain vs multi-strain preparations, and better effectiveness of high dose (> 5 billion CFU/day) than low dose (<5 billion CFU/day) treatments.
- The species with the most research and most consistent effect were Lactobacillus rhamnosus (strains GG, ATCC53103, E/N, Oxy, Pen) and Saccharomyces boulardi which is a strain of the beer making yeast Saccharomyces cerevisiae.
Grading
Moderate certainty evidence.
The evidence is from systematic reviews of randomised trials, however research to date has used such a wide range of microbes and doses that the strength of evidence may change in the future.