Probiotic

Aka: Probiotic, Human Microbiota, Gut Flora

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II. Definitions

  1. Probiotic
    1. Microorganisms taken as dietary supplements to help improve intestinal microbial balance
  2. Human Microbiota (esp. Gut Flora)
    1. Microbes that colonize human body, influenced by vertical transmission, environment (e.g. pets), diet

III. Indications

  1. Prevention of Antibiotic-Associated Diarrhea
    1. Unclear if effective for Clostridium difficile, but does appear to decrease Antibiotic Associated Diarrhea (NNT 13)
    2. Best evidence is for Lactobacillus rhamosus GG (Culturelle) and Saccharomyces boulardii (Florastor)
    3. Start within 3 days of initiating Antibiotic course and continue for 3 days after completing course
    4. Separate the doses of Antibiotic and Probiotic by at least 2 hours
    5. (2020) Presc Lett 27(9): 49-50
  2. Irritable Bowel Syndrome
  3. Atopic Dermatitis in Infants
  4. Infectious Diarrhea (Gastroenteritis)
    1. Lactobacillus does not appear to reduce Diarrhea in Children
    2. Schnadower (2018) N Engl J Med 379(21):2002-14 [PubMed]

IV. Physiology

  1. Human Gastrointestinal Microbiota may have an impact on Obesity and human disease
  2. High fiber diet from various sources encourages a more diverse Gut Flora and may result in improved health
  3. Resources
    1. Nature Journal - Microbiota
      1. https://www.nature.com/nature/focus/humanmicrobiota/index.html
  4. References
    1. Sonnenberg (2018) Healthy Kitchens Conference, Harvard and Culinary Institute, St. Helena, CA

V. Contraindications

  1. Severe immunompromised state
  2. Short-Gut Syndrome (relative contraindication)
  3. Some Probiotic preparations may contain gluten (avoid in Celiac Sprue)

VI. Dosing

  1. Children: 5-10 Billion Colony Forming Units per day
  2. Adults: 10-20 Billion Colony Forming Units per day

VII. Components (most brands contain a mixture of multiple Probiotic strains)

  1. Lactobacillus species
    1. Lactobacillus acidophilus
    2. Lactobacillus rhamnosus
    3. Lactobacillus bulgaricus
  2. Bifidobacterium species
    1. Bifidobacterium bifidum
    2. Bifidobacterium longum
  3. Saccharomyces species

VIII. Preparations

  1. Precautions
    1. Most significant factor affecting efficacy appears to be at least 5-10 Billion CFUs
    2. Specific organisms appear to have less of an impact on efficacy
  2. Activa yogurt (5-10 B CFU/container), Align (1 B CFU/cap)
    1. Bifidobacterium species
  3. Bio-K Plus (12.5 B CFU/cap), Bacid (1 B CFU/cap), Lactinex (1 M CFU/tab)
    1. Lactobacillus species
  4. Culturelle (10 B CFU/cap)
    1. Lactobacillus rhamosus
  5. DanActive yogurt drink (1 B CFU/3 oz)
    1. Lactobacillus species
    2. Streptococcus species
  6. Jamieson Probiotic Sticks (3 billion CFU/stick)
    1. Lactobacillus species
    2. Bifidobacterium species
  7. Iflora Multi-Biotic (16 B CFU/cap), Probiotic-10 (25 B CFU/cap)
    1. Lactobacillus species
    2. Streptococcus species
    3. Bifidobacterium species
  8. Kefir fermented milk drink (7-10 B CFU/8 oz)
    1. Bifidobacterium species
    2. Lactobacillus species
    3. Leuconostoc species
    4. Saccharomyces florentinus
  9. Florastor (1 B CFU/cap)
    1. Saccharomyces boulardii
  10. Garden of Life Raw Probiotics Ultimate Care (100 B CFU/cap)
    1. Bifidobacterium species
    2. Lactobacillus species
    3. Leuconostoc species
    4. Saccharomyces species
    5. Streptococcus species
    6. Additional 5 Bacteria distinct to this formulation (unknown efficacy)

IX. Adverse Effects

  1. Flatulence
  2. Abdominal discomfort

X. Drug Interactions

  1. None

XI. Efficacy

  1. See Infantile Colic
  2. See Necrotizing Enterocolitis
  3. Antibiotic Associated Diarrhea significantly reduced if Probiotics started in first 3 days of Antibiotics
    1. Prevents Antibiotic Associated Diarrhea (NNT 12) and Clostridium difficile (NNT 29)
    2. Probiotic examples: Bio-K+, Culturelle, DanActive, Florajen or Florastor
      1. Take 2 hours after each Antibiotic dose
      2. Continue for up to 2 weeks after completing Antibiotics
    3. Sazawal (2006) Lancet Infect Dis 6(6): 374-82 [PubMed]
    4. McFarland (2006) Am J Gastroenterol 101(4): 812-22 [PubMed]
  4. Acute Infectious Diarrhea reduced duration with Probiotics
    1. May shorten Diarrhea course by one day
    2. May also prevent Traveler's Diarrhea
    3. Canani (2007) BMJ 335(7615):340 [PubMed]
  5. Constipation
    1. Improves stooling frequency and symptoms in both children and adults with Functional Constipation
    2. Ford (2014) Am J Gastroenterol 109(10): 1547-61 [PubMed]
    3. Guerra (2011) World J Gastroenterol 17(34): 3916-21 [PubMed]
  6. Irritable Bowel Syndrome with reduced symptoms in women on Probiotics
    1. Whorwell (2006) Am J Gastroenterol 101(7): 1581-90 [PubMed]
  7. Ulcerative Colitis
    1. Increases remission rates with Ulcerative Colitis flares
    2. Shen (2014) Inflamm Bowel Dis 20(1): 21-35 [PubMed]
  8. Atopic Disease development risk may be reduced with Probiotics in infants
    1. Kalliomaki (2001) Lancet 357:1076-9 [PubMed]
  9. Other conditions with mixed or inconclusive data to support Probiotic use
    1. Helicobacter Pylori infection
    2. Hepatic Encephalopathy
    3. Nonalcoholic Steatohepatitis (NASH)

XII. References

  1. Doron (2005) Gastroenterol Clin North Am 34(3): 483-98 [PubMed]
  2. Kligler (2008) Am Fam Physician 78(9): 1073-8 [PubMed]
  3. Wilkins (2017) Am Fam Physician 96(3): 170-8 [PubMed]

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