Probiotics: preventing antibiotic-associated diarrhea.
ABSTRACT Probiotics are live microorganisms that offer a health benefit to the host. Found typically in dietary supplements, probiotics can be safely used in the treatment of acute diarrheal disease, inflammatory bowel disease, and antibiotic-associated diarrhea. They can be found in milks, yogurt, powders, and pills.
Research has shown that several strains of probiotics are helpful in the prevention and treatment of antibiotic-associated diarrhea. The most commonly studied probiotics are Lactobacillus GG and Saccharomyces boulardii.
By understanding the uses, dosages, and safety of common probiotics, nurses can help educate patients and their families on the benefits of probiotics.
Probiotics: Preventing Antibiotic-Associated
PURPOSE. Probiotics are live microorganisms
that offer a health benefit to the host. Found
typically in dietary supplements, probiotics can
be safely used in the treatment of acute diarrheal
disease, inflammatory bowel disease, and
antibiotic-associated diarrhea. They can be found
in milks, yogurt, powders, and pills.
CONCLUSIONS. Research has shown that several
strains of probiotics are helpful in the prevention
and treatment of antibiotic-associated diarrhea.
The most commonly studied probiotics are
Lactobacillus GG and Saccharomyces
PRACTICE IMPLICATIONS. By understanding the
uses, dosages, and safety of common probiotics,
nurses can help educate patients and their
families on the benefits of probiotics.
Search terms: Antibiotic-associated diarrhea,
Lactobacillus GG, probiotics, Saccharomyces
Kathleen Jones, MSN, CPNP, is a Primary Care Pediatric
Nurse Practitioner in Private Practice, Orlando, Florida,
Probiotics have become increasingly popular in the United
States over the last 10 years, but they have been studied for
many years. In 1908, Dr. Eli Metchnikoff won the Nobel Prize
in medicine for his research on probiotics. Dr. Metchnikoff
was the first to officially propose that ingesting certain bac-
teria could help replace harmful microbes in the body. He
proposed that increasing the amount of sour milk consumed,
or dairy drinks with live bacteria, was associated with
increased longevity (Isolauri et al., 2002). This concept is
believed to be the beginning of the evolution of the study of
probiotics. Probiotics are “live microorganisms” that, in
certain dosages, can result in a health benefit to the host.
Probiotics modify the microflora of the intestine, which
results in antibacterial substances being secreted, and then,
the probiotics compete with pathogens to prevent adherence
to the intestinal epithelium (Land & Martin, 2008; Michail,
Sylvester, Fuchs, & Issenman, 2006).
The gastrointestinal tract of a newborn baby, at birth, is
sterile. Bacteria that are ingested during the birthing process
colonize the gastrointestinal tract. Subsequently, our intesti-
nal flora is most similar to our mother’s intestinal flora. In
addition, the intestinal tract has 10 times as many bacteria as
cells in the human body. It is these bacteria that are respon-
sible for priming the immune system. Without these bacteria,
the immune system would not function properly (Vander-
hoof & Young, 2002). Isolauri and colleagues (2002) referred
to the gastrointestinal tract as the most metabolically active
organ in the human body.
The types of bacteria that colonize the infant depend on
several things, such as the type of delivery (vaginal vs. Cesar-
ean section), age at birth, and the type of feeding (breast-
feeding vs. formula feeding; Kligler, Hanaway, & Cohrssen,
2007). Infants born via Cesarean section appear to have
delayed colonization with Bifidobacterium and Bacteroides
(Vael & Desager, 2009). Breast-fed infants appear to have
intestinal tracts that primarily contain bifidobacteria. This is
thought to have an effect on the occurrence and virulence of
food that humans ingest travels through the intestines and
interact along the way. Our environment is heavily colonized
with many microorganisms. In the modern movement to
First received September 16, 2009; Revision received Novem-
ber 14, 2009; Accepted for publication November 29, 2009.
doi: 10.1111/j.1744-6155.2010.00231.x© 2010, Wiley Periodicals, Inc.
sterilize the environment and protect the host, many non-
pathogenic bacteria, which are actually helpful to the host,
are being destroyed (Saavedra, 2001).
Probiotics are thought to contribute to intestinal homeo-
stasis in the midst of this modern invasion of sterility. They
are used in the treatment of acute infectious diarrhea, irri-
table bowel syndrome, antibiotic-associated diarrhea (AAD),
inflammatory bowel disease, and allergic disease. In the past
10 years, the amount of research on probiotics has dramati-
cally increased (Land & Martin, 2008).
Probiotics are used in the prevention of AAD. Antibiotics
are commonly prescribed in the treatment of children with
illnesses such as otitis media, streptococcal pharyngitis,
pneumonia, and cellulitis. Children are estimated to use
three times more antibiotics than adults (Szajewska, Ruszc-
zynski, & Radzikowski, 2006). While these antibiotics may
cure disease, they can result in unwanted side effects like
diarrhea. Antibiotics, such as aminopenicillins, cephalospor-
ins, and clindamycin, that fight anaerobes more often cause
diarrhea. These antibiotics alter the intestinal microflora of
the patient, leading to crampy abdominal pain and diarrhea
(Johnston, Supina, Ospina, & Vohra, 2007).
Diarrhea is defined by the World Health Organization
(2009) as three or more loose or liquid stools in a 24-hr period
or more frequent stool than is normal for the individual.
AAD is thought to occur in 11–40% of children between the
initiation of antibiotics and 2 months after their completion
(Szajewska et al., 2006).
Administration of Lactobacillus GG (LGG) has been shown
to reduce AAD risk by 75% in children in the United States
(Vanderhoof & Young, 2002). Saccharomyces boulardii, a yeast,
has also shown the ability to reduce the risk ofAAD (Vander-
hoof & Young, 2002).
Several randomized controlled trials have been conducted
shown a statistically significant reduction in AAD in those
patients taking probiotics compared with placebo. In a meta-
analysis by Szajewska et al. (2006), six randomized controlled
trials were included. Probiotics decreased the risk of AAD
from 28.5% to 11.97%. Thus, for every seven patients taking
probiotics with their antibiotics, one less patient developed
diarrhea. In these same studies, LGG, S. boulardii, and Bifido-
bacterium lactis with Streptococcus thermophilus were associ-
ated with decreasing AAD. In general, the length of diarrhea
in the study participants was decreased by a total of 1 day
(Szajewska et al., 2006).
In another meta-analysis by Johnston et al. (2007), 10 ran-
domized controlled studies were evaluated. According to the
authors, probiotics significantly decreased the incidence of
diarrhea. The mean decrease in duration of diarrhea because
of probiotics in these studies was three quarters of a day. A
limitation in these studies was that the dose of probiotics
used varied between the studies, thus making it difficult to
determine the dosage of probiotics necessary.
Probiotic products come in many preparations. They are
available in milk, infant formula, and yogurt as well as in
powders and pills. The most common probiotics are bifido-
bacteria and lactobacilli. The standard accepted dosing is
between 1 and 10 million colony-forming units (CFU) daily
(Saavedra, 2001). According to a meta-analysis by Johnston
et al. (2007), the evidence suggested that a dose of 5–40
billion CFU/day of LGG or S. boulardii had the most promise
of decreasing AAD. Few studies have been completed to
determine the exact dosage required to colonize the intestine,
but most researchers agree that the dose should likely be
greater than or equal to 5 billion CFU per day (Boyle, Robins-
Browne, & Tang, 2006; Johnston et al., 2007).
Two popular over-the-counter preparations are Floras-
tor® (Bicodex, San Bruno, CA) and Culturelle® (Amerifit
Brands, Inc., Cromwell, CT). Florastor® is composed of the
yeast S. boulardii. It is dispensed as a powder or capsule. The
dose recommended by the manufacturer for AAD is one to
two capsules twice a day. Each capsule contains 5 billion CFU
(Bicodex, 2009). Culturelle® is a newer probiotic composed
of LGG. LGG is the best studied and most documented pro-
biotic strain available. Each capsule of Culturelle® contains
10 billion CFU of LGG and is recommended for once-a-day
dosing (Amerifit Brands, Inc., 2009).
The large number of probiotic preparations on the market
makes it more difficult to create generalized recommenda-
tions for probiotic use. Many of the products found in phar-
macies and health food stores are neither reliable nor
effective, and consumers need to understand that all probi-
otics are not created equal. For example, many probiotics are
ineffective because they are unable to survive gastric and bile
acids, unable to colonize the intestine, and ineffective at
binding to epithelial cells in the intestine. Those probiotics
strains showing the most promise are LGG, bifidobacteria,
and S. boulardii (Saavedra, 1999; Vanderhoof et al., 1999).
Probiotics, in the powder or the pill form, are classified as
a dietary supplement. Thus, they fall under different regula-
tions than medications. Based on the Dietary Supplement
Health and Education Act of 1994, supplements that existed
prior to 1994 are not required to be reviewed by the U.S.
Food and Drug Administration (FDA). Products marketed
after 1994 must provide the FDA with information showing
that the supplement/product is safe for use in humans. The
JSPN Vol. 15, No. 2, April 2010161
manufacturers do not have to provide factual evidence that
these products are effective and safe, although they are not
permitted to market products that are not safe and effective
(National Institutes of Health Office of Dietary Supplements,
n.d.). Once the supplement makes it to the marketplace, the
FDA must prove that the product is unsafe or ineffective to
have it removed from the market. Product labels should be
truthful and not misleading (National Institutes of Health
Office of Dietary Supplements, n.d.).
While probiotics are generally considered very safe, there
are several case reports of sepsis in adults and children after
the ingestion of probiotics. All cases of bacteremia and
fungemia in children have occurred in premature infants,
those children with underlying immune compromise, and
children with central venous catheters (Boyle et al., 2006). In
addition, there was a study conducted by Besselink and col-
leagues (2008) that recommended that probiotics not be
administered routinely in patients with severe acute pancre-
atitis.An increase in mortality rates was observed in the adult
patients they studied.
With their good safety profile and studies proving their
efficacy, probiotics will continue to be used. In addition, their
effect on the immune system interests many researchers.
Many future uses of probiotics have been suggested. These
include: control of inflammatory diseases, treatment and pre-
vention of allergies, cancer prevention, immune stimulation,
and reduction of respiratory disease.
How Do I Apply This Evidence to Nursing
By understanding the uses, dosages, and safety of probi-
otics, nurses can give their patients accurate information on
another way to improve their health. In addition, probiotics
can help patients avoid the unwanted side effects, such as
AAD, of certain medical therapies. Many parents stop treat-
ment with antibiotics against their medical provider’s recom-
mendations in order to avoid diarrhea. Probiotic use may be
one way to achieve greater compliance with antibiotic treat-
ment in the pediatric population.
Author contact: kajrn@aol, with a copy to the Editor:
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Probiotics: Preventing Antibiotic-Associated Diarrhea
162JSPN Vol. 15, No. 2, April 2010
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