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Coadministration of Probiotics With Antibiotics
Why, When and for How Long?
Lyudmila Boyanova; Ivan Mitov
Posted: 05/09/2012; Expert Rev Anti Infect Ther. 2012;10(4):407-409. © 2012 Expert Reviews Ltd.
Abstract and Introduction
Introduction
Probiotics, such as Lactobacillus spp., Bifidobacterium spp. and Saccharomyces boulardii, are living microorganisms that confer health benefits on the host. They are taken with food or as capsules/tablets and powder. Probiotics improve antibiotic therapy as they reduce microbial adhesion and growth by bacteriocins or other inhibitory compounds, possess immunomodulatory properties and improve intestinal barrier integrity. In patients treated with antibiotics, probiotics promote the recovery of commensal microbiota and increase treatment tolerability.
Probiotics exhibit an excellent overall safety profile but should be used cautiously in severely immunocompromised patients and premature neonates. In fragile patients, there is a risk of bacteremia by some Lactobacillus spp. (e.g., Lactobacillus rhamnosus GG and Lactobacillus casei). S. boulardii should be avoided in patients who are critically ill, at parenteral nutrition or with central venous catheters due to risk for fungemia. Antibiotic resistance of the probiotic strains should be considered as it could be transferred to other species, although transfer from lactobacilli has been observed occasionally in vivo in diassociated animal models.
Dysbiosis
Antibiotic use can lead to dysbiosis. In our study [Boyanova L, Unpublished Data], 4.5% of 67 patients evaluated for Helicobacter pylori exhibited false-positive13C urea breath test results (Richen-Force, Beijing, China) due to non-H. pylori Gram-negative bacteria isolated from gastric biopsies. Additionally, we observed Candida overgrowth in 24.1% of 58 fecal specimens from treated patients sent for Campylobacter diagnostics [Boyanova L, Unpublished Data]. Probiotics reduce the risk of antibiotic-induced super infections. Orally/intravaginally administered Lactobacillus acidophilus, L. rhamnosus GR-1 and Lactobacillus fermentum RC-14 can prevent vulvovaginal candidiasis.[6] Consuming L. rhamnosus GG-containing cheese for 16 weeks reduced the risk of high yeast counts by 75% in elderly people.[7] Probiotic administration is promising alongside antibiotic treatment of bacterial vaginosis. When a single dose of tinidazole (2g) was supplemented with L. rhamnosus GR-1 and Lactobacillus reuteri RC-14 for 4 weeks, the cure rate of bacterial vaginosis increased by >37% compared with the placebo group.[8]
Antibiotic-associated Diarrhea & Clostridium difficile-associated Diarrhea
Diarrhea occurs in 5–39% of patients treated by antibiotics.[9] Clostridium difficile -associated diarrhea (CDAD) encompasses 10–25% of antibiotic-associated diarrhea (AAD) cases, and hypervirulent C. difficile strain (ribotype 027) additionally increases the severity of the disease.[10] Clostridium perfringens, Bacteroides fragilis, Klebsiella oxytoca, Staphylococcus aureus and fungi can also cause AAD. Clindamycin, cephalosporins and, recently, fluoroquinolones are associated with highest risk for CDAD. Other at-risk patients are elderly subjects, hospitalized and oncologic patients, and users of proton-pump inhibitors. Importantly, the probiotic use can decrease the risk of AAD by >50% but should start within 72 h of the onset of antibiotic therapy.[11]
Use of probiotics can be recommended for prophylaxis of AAD and CDAD in patients treated by broad-spectrum antibiotics, especially in high-risk antibiotic recipients. For this purpose, L. rhamnosus GG and S. boulardii are used, the latter inhibiting C. difficile toxin effects.[9] Mixture, including L. acidophilus CL1285 or fermented milk of L. casei DN-114001,Lactobacillus delbrueckii subsp. bulgaricus and Streptococcus thermophilus can also diminish the risk of AAD and CDAD.[11] L. delbrueckii spp. bulgaricus B-30892 shows promising in vitro results.[12] Coadministration of S. boulardii, L. rhamnosus GG, Lactobacillus plantarum 299v, L. acidophilus and Bifidobacterium bifidum and oral metronidazole or vancomycin has been reported in CDAD treatment.[12] Notably, not all strains of a species provide the expected activity.
H. pylori eradication
H. pylori eradication often fails due to antibiotic resistance or adverse effects of therapy. Lactobacillus spp. exhibit anti-H. pylori activity in vitro, inhibiting H. pylori urease activity and adhesion, secreting short-chain fatty acids, bacteriocins/bacteriocin-like substances and acting as immunomodulators. Adding probiotics to regimens reduces side effects by 11–23% and may slightly improve eradication rates by ≤ 5–15%.[3,13] The so-far most-active Lactobacillus strains are L. casei and Lactobacillus johnsonii La1.[13] Although it is controversial whether the probiotics reduce development of antibiotic resistance in the intestinal microflora, in two studies, ingestion of probiotics (L. acidophilus and Bifidobacterium strains or cheese) was found to reduce the emergence of resistant enterococci.[14,15] Activity of the lactobacilli is species and strain specific. Probiotic mixtures should be considered carefully as the proinflammatory activity of one probiotic can mask the anti-inflammatory effect of the others.[16] Another treatment adjunct is S. boulardii, which is immunomodulatory and inhibits bacterial adhesion and toxins. According to Szajewska et al.,[17] S. boulardii supplementation on triple regimens improves the treatment success by 9% and diminishes adverse effects of therapy by 11.4%, especially diarrhea. Briefly, probiotics reduce the side effects of H. pylori regimens and may slightly increase eradication success.
Dosage & Treatment Duration of Probiotics
The suggested probiotic amount for intestinal colonization is ≥5 × 109CFU/day.[18] Lactobacilli are administered in high numbers, usually 5–10 × 109CFU/day for children and 10–20 × 109CFU/day for adults for ≥5 days. Dosage of S. boulardii is most often 250–1000 mg daily.[11,17] At 5–40 × 109CFU/day, L. rhamnosus GG or S. boulardii are most protective against pediatric AAD.[19] Unlike S. boulardii, the lactobacilli can be inhibited by antibiotics and should be taken at least 2–4 h after the antibiotic dose. Choice of probiotic strains, appropriate dosage and prolonged consumption are necessary for stable benefits.
Probiotics are often prescribed for 1–3 weeks longer than the duration of antibiotic treatment.[17,101] They should be taken with food because the increased gastric pH is more favorable for the probiotics.
Conclusion
Probiotics are a valuable adjunct to antibiotic therapy. For their coadministration with antibiotics, further studies evaluating strain selection by molecular methods, optimal dosage, treatment duration and more target populations will reveal the full multifaceted potential of the friendly microorganisms.
References
Reid G. Probiotics to prevent the need for, and augment the use of, antibiotics. Can. J. Infect. Dis. Med. Microbiol. 17(5), 291–295 (2006).
Gupta V, Garg R. Probiotics. Indian J. Med. Microbiol. 27(3), 202–209 (2009).
Boyanova L. Non-antibiotic agents in the treatment of H. pylori infection. In: Helicobacter pylori. Boyanova L. (Ed.). Caister Academic Press, Norfolk, UK, 253–275 (2011).
Schjørring S, Krogfelt KA. Assessment of bacterial antibiotic resistance transfer in the gut. Int. J. Microbiol. 2011, 312956 (2011).
Koduganti RR, Sandeep N, Guduguntla S, Chandana Gorthi V. Probiotics and prebiotics in periodontal therapy. Indian J. Dent. Res. 22(2), 324–330 (2011).
Falagas ME, Betsi GI, Athanasiou S. Probiotics for prevention of recurrent vulvovaginal candidiasis: a review. J. Antimicrob. Chemother. 58(2), 266–272 (2006).
Hatakka K, Ahola AJ, Yli-Knuuttila H et al. Probiotics reduce the prevalence of oral candida in the elderly – a randomized controlled trial. J. Dent. Res. 86(2), 125–130 (2007).
Martinez RC, Franceschini SA, Patta MC et al. Improved cure of bacterial vaginosis with single dose of tinidazole (2 g), Lactobacillus rhamnosus GR-1, and Lactobacillus reuteri RC-14: a randomized, double-blind, placebo-controlled trial. Can. J. Microbiol. 55(2), 133–138 (2008).
Hickson M. Probiotics in the prevention of antibiotic-associated diarrhoea and Clostridium difficile infection. Therap. Adv. Gastroenterol. 4(3), 185–197 (2011).
Blossom DB, McDonald LC. The challenges posed by reemerging Clostridium difficile infection. Clin. Infect. Dis. 45(2), 222–227 (2007).
Kligler B, Cohrssen A. Probiotics. Am. Fam. Physician. 78(9), 1073–1078 (2008).
Banerjee P, Merkel GJ, Bhunia AK. Lactobacillus delbrueckii ssp. bulgaricus B-30892 can inhibit cytotoxic effects and adhesion of pathogenic Clostridium difficile to Caco-2 cells. Gut Pathog. 1(1), 8(2009).
Lesbros-Pantoflickova D, Corthésy-Theulaz I, Blum AL. Helicobacter pylori and probiotics. J. Nutr. 137(Suppl. 2), 812S–8128S (2007).
Plummer SF, Garaiova I, Sarvotham T et al. Effects of probiotics on the composition of the intestinal microbiota following antibiotic therapy. Int. J. Antimicrob. Agents 26(1), 69–74 (2005).
Bertrand X, Dufour V, Millon L et al. Effect of cheese consumption on emergence of antimicrobial resistance in the intestinal microflora induced by a short course of amoxicillin-clavulanic acid. J. Appl. Microbiol. 102(4), 1052–1059 (2007).
Myllyluoma E, Ahonen AM, Korpela R, Vapaatalo H, Kankuri E. Effects of multispecies probiotic combination on Helicobacter pylori infection in vitro. Clin. Vaccine Immunol. 15(9), 1472–1482 (2008).
Szajewska H, Horvath A, Piwowarczyk A. Meta-analysis: the effects of Saccharomyces boulardii supplementation on Helicobacter pylori eradication rates and side effects during treatment. Aliment. Pharmacol. Ther. 32(9), 1069–1079 (2010).
Jones K. Probiotics: preventing antibiotic-associated diarrhea. J. Spec. Pediatr. Nurs. 15(2), 160–162 (2010).
Johnston BC, Goldenberg JZ, Vandvik PO, Sun X, Guyatt GH. Probiotics for the prevention of pediatric antibiotic-associated diarrhea. Cochrane Database Syst. Rev. 11, CD004827 (2011).
Website
101 Biradar SS, Bahagvati ST, Shegunshi B. Probiotics and antibiotics: a brief overview. Internet J. Nutr. Wellness 2(1), (2005). www.ispub.com/journal/the-internetjournal-of-nutrition-and-wellness/volume-2-number-1/probiotics-and-antibiotics-abrief-overview.html
Expert Rev Anti Infect Ther. 2012;10(4):407-409. © 2012 Expert Reviews Ltd.