I have been reading with interest the eTalk thread on the topic of probiotics following antibiotic administration that can be found on PRESENT Podiatry. This is an interesting topic, and one that I felt would be germane to the on-going discussion regarding the knowledge base that we obtain throughout our residency training and into our clinical practices. Throughout my residency training, very little was said about probiotic supplementation in conjunction with antibiotic therapy. However, recently I have noted with increasing curiosity that the hospitalists in my hospital seem to be ordering probiotics on essentially every patient who is concomitantly started on antibiotic therapy.
Has this become the new “standard of care” ? The answer may surprise you. There is certainly increasing literature to support the use of probiotic therapy in patients who are concomitantly receiving antibiotic therapy.
It is well known that a “normal,” healthy gut is colonized by a variety of “good” bacterial species, and that these bacteria help to promote healthy digestion, as well as immune function. The normal, naturally occurring bacteria found in the upper intestine include lactobacilli and enterococci (such as Enterococcus faecalis). Microbes of the lower intestine and colon include mostly anaerobes, where greater than 90% are anaerobes (such as Bacteroides and Clostridium.), enterics (Escherichia coli and relatives), Pseudomonas, and Candida.1 While many of these can become pathogenic in circumstances we are all familiar with, they do serve a useful purpose within the gastrointestinal tract.
Probiotics are live bacterial species (commonly lactic acid bacteria (LAB) and bifidobacteria) which, when ingested in appropriate doses, demonstrate a positive health benefit to the host. A recently published article in the International Journal of Antimicrobial Agents suggests that the beneficial effects of probiotics are accomplished through three fundamental mechanisms:2
- Modulation of the content of gut microbiota
- Maintenance of the integrity of the gut barrier and prevention of bacterial translocation;
- Modulation of the local immune response by the gut-associated immune system.
The specific health effects of probiotics are currently under investigation, and though further research is necessary, a search of PubMed demonstrates an increasing number of scholarly articles in which the use of probiotics were correlated with positive patient outcomes, including alleviation of chronic intestinal inflammatory diseases,1 prevention and treatment of pathogen-induced diarrhea,3 urogenital infections,4 and atopic diseases.
The Kotzampassi study found that sufficient evidence existed to support the use of [probiotic’s] role in decreasing the incidence of antibiotic-associated diarrhea (AAD), Clostridium difficile infection (CDI), acute gastroenteritis—particularly when administered in conjunction with antimicrobials—in the ICU patient population utilized in for the study.2
What does this mean for us as podiatric surgeons? Clearly there is literature to support the use of probiotics in patients receiving concomitant antimicrobial therapies, and as providers who commonly prescribe numerous antibiotics, it is important that we critically evaluate the literature that addresses the potential complications from the use of these medications. We must always be on guard. In a local hospital here in Virginia, there were 31 deaths in 2011 due to Clostridium difficile infections—several of which were iatrogenic. These types of infections do carry significant morbidly and mortality, and it is important to medically treat our patients to reduce this risk. Probiotics, the literature suggests, do provide some protective effects to reduce the risks of AAD and CDI in our compromised patient populations.
What, if any, is your experience with the use of probiotic therapies? It has been fascinating to follow along the eTalk thread. I would encourage you to share your experiences, thoughts, or questions on the topic there.
References:
- Mach T (November 2006). "Clinical usefulness of probiotics in inflammatory bowel diseases". Journal of Physiology and Pharmacology 57 Suppl 9: 23–33.
- Kotzampassi K, Evangelos J. Giamarellos-Bourboulis Probiotics for infectious diseases: more drugs, less dietary supplementation. International Journal of Antimicrobial Agents - 06 August 2012
- Yan F, Polk DB (November 2006). "Probiotics as functional food in the treatment of diarrhea". Current Opinion in Clinical Nutrition and Metabolic Care 9 (6): 717–21.
- Reid G (September 2008). "Probiotic Lactobacilli for urogenital health in women". J. Clin. Gastroenterol. 42 (Suppl 3 Pt 2): S234–6.
- Vanderhoof JA (November 2008). "Probiotics in allergy management". Journal of Pediatric Gastroenterology and Nutrition 47 Suppl 2: S38–40.
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