Recommendations for probiotic use-2011 update.
ABSTRACT This study describes the consensus opinion of the participants of the third Yale Workshop on probiotic use. There were 10 experts participating. The recommendations update those of the first 2 meetings that were published in 2005 and 2008. The workshop presentations and papers in this supplement relate to the involvement of normal microbiota involved in intestinal microecology, how the microbes interact with the intestine to affect our immunologic responses, the stability and natural history of probiotic organisms, and the role of the intestinal microbatome with regard to affecting cardiac risk factors and obesity. Recommendations for the use of probiotics in necrotizing enterocolitis, childhood diarrhea, inflammatory bowel disease, irritable bowel syndrome, and Clostridium difficile diarrhea are reviewed. As in previous publications, the recommendations are given as A, B, or C ratings. The recent positive experiences with bacteriotherapy (fecal microbiome transplant) are also discussed in detail and a positive recommendation is made for use in severe resistant C. difficile diarrhea.
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ABSTRACT: The aim was to evaluate the effects of orally administered Lactobacillus rhamnosus GG (LGG) and Bifidobacterium animalis subsp. lactis BB-12 (BB-12) on the number of salivary mutans streptococci (MS), amount of plaque, gingival inflammation and the oral microbiota in healthy young adults. The study was a randomised, controlled, double-blind trial. Healthy volunteers used lozenges containing a combination of LGG and BB-12 (test group, n = 29) or lozenges without added probiotics (control group, n = 31) for 4 weeks. At baseline and at the end of the test period, the plaque index (PI) and gingival index (GI) were determined, and stimulated saliva was collected. The microbial composition of saliva was assessed using human oral microbe identification microarray (n = 30). MS and lactobacilli (LB) were plate cultured. The probiotic lozenge decreased both PI and GI (p < 0.05) while no changes were observed in the control group. However, no probiotic-induced changes were found in the microbial compositions of saliva in either group. The probiotic lozenge improved the periodontal status without affecting the oral microbiota. Short-term consumption of LGG and BB-12 decreased the amount of plaque which was associated with a clinical impact: a decrease in gingival inflammation.Clinical Oral Investigations 03/2014; · 2.20 Impact Factor
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ABSTRACT: Guidelines consider certain probiotics useful in the management of acute gastroenteritis. This study evaluated the use of Lactobacillus (L) reuteri DSM 17938. A multicenter, randomised, single blind, clinical trial was performed in hospitalised children with acute gastroenteritis lasting 12 to 72 hours. Children received conventional therapy with, or without, 1x10(8) CFU of L reuteri DSM 17938 for five days. The primary endpoint was the duration of diarrhoea and secondary outcomes were days of hospitalisation and the percentage of children with diarrhoea after each day of treatment. We compared 64 children receiving L reuteri group with 63 controls. L reuteri reduced the duration of diarrhoea after 24 hours (p<0.001) and more diarrhoea-free children were seen in the L reuteri than control group after 24 and 48 hours (50% versus 5%, p<0.001) and 72 hours (69% versus 11%, p<0.001). L reuteri reduced mean hospital stays (4.31 ± 1.3 days versus 5.46 ± 1.77 days, p<0.001). Prolonged diarrhoea occurred in 17% of the controls, but none of the L reuteri group. No adverse effects were reported. L reuteri effectively reduced the duration of acute diarrhoea and hospital stays in children hospitalised with acute gastroenteritis. Outpatient data is now required. This article is protected by copyright. All rights reserved.Acta Paediatrica 03/2014; · 1.97 Impact Factor
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ABSTRACT: Probiotics are microorganisms exerting beneficial effects on the host. They can be ingested through foods or supplements and their inclusion in these products is regulated in Canada by the Health Canada Health Products and Food Branch. The aim of this article is to summarize current evidence from randomized controlled trials and guidelines from Health Canada, the World Health Organization, and internationally recognized expert committees in the hope that it will help practitioners and professionals recommending probiotics to healthy and diseased patients, with a focus on the Canadian setting. From a general perspective, probiotics can be recommended for prevention of diseases that are associated to altered intestinal ecology. Specifically, they can be recommended for prevention of upper respiratory tract infections and pouchitis, for prevention and management of necrotizing enterocolitis, bacterial vaginosis and antibiotic associated diarrhea, including Clostridium difficile infection, and for treatment of atopic eczema in cow's milk allergy and of infectious diarrhea. Additional substantiated probiotic benefits include prevention of hypercholesterolemia, management of constipation, reduction of recurrent urinary tract infections, improvement of irritable bowel syndrome symptoms, and reduction of antibiotics side effects in Helicobacter pylori eradication. Because probiotics are generally recognized as safe and can be removed with antimicrobial agents, their use should be considered in patients of all ages.Applied Physiology Nutrition and Metabolism 05/2014; · 2.01 Impact Factor
Recommendations for Probiotic Use—2011 Update
Martin H. Floch, MD,* W. Allan Walker, MD,w Karen Madsen, PhD,z Mary Ellen Sanders, PhD,y
George T. Macfarlane, PhD,8 Harry J. Flint, PhD,z Levinus A. Dieleman, MD, PhD,z
Yehuda Ringel, MD,# Stefano Guandalini, MD,** Ciaran P. Kelly, MD,ww
and Lawrence J. Brandt, MDzz
Abstract: This study describes the consensus opinion of the
participants of the third Yale Workshop on probiotic use. There
were 10 experts participating. The recommendations update those of
the first 2 meetings that were published in 2005 and 2008. The
workshop presentations and papers in this supplement relate to the
involvement of normal microbiota involved in intestinal micro-
ecology, how the microbes interact with the intestine to affect our
immunologic responses, the stability and natural history of probiotic
organisms, and the role of the intestinal microbatome with regard to
affecting cardiac risk factors and obesity. Recommendations for the
use of probiotics in necrotizing enterocolitis, childhood diarrhea,
inflammatory bowel disease, irritable bowel syndrome, and
Clostridium difficile diarrhea are reviewed. As in previous publica-
tions, the recommendations are given as A, B, or C ratings. The
recent positive experiences with bacteriotherapy (fecal microbiome
transplant) are also discussed in detail and a positive recommenda-
tion is made for use in severe resistant C. difficile diarrhea.
Key Words: probiotics, recommendations, diarrhea
(J Clin Gastroenterol 2011;45:S168–S171)
wide attention of patients and health care delivery
personnel, but although there was a growing literature on
clinical trials, there were few clinical recommendations.
Hence, we gathered thought leaders and investigators in the
field and published the first workshop recommendations in
2005.1We held the second workshop with some of the
original contributors but added others to broaden our view.
The results of the second workshop were published in
This paper3represents the work of 10 experts of the
third Yale Workshop held in New Haven in April 2011.
Dr Walker and I designed this program in an effort
to include the newer concepts on the use of probio-
tics to maintain health. The work presented explores
probiotic interaction with the immune system.4
importance of these interactions to overall host health is
not yet fully understood. Questions such as how much
do supplemental probiotic organisms contribute to immune
status compared with the natural physiologic effects of
the microbiome?, can a single organism have an impor-
tant impact?, or are multiple organisms needed? are
We also included in this workshop a discussion of the
effects of colonic fermentation on health6and how it may
affect cardiac risk factors. The early concepts of how the
microbiome may affect obesity also are covered.7The
supplement includes detailed articles on all of these factors.
We reviewed the recommendations in diseases made in
2005 and 2008 and updated them. Updates on inflammatory
bowel disease,8the irritable bowel syndrome,9infectious
diarrhea,10and Clostridium difficile infection are given.11
The user should be aware that some of the recom-
mendations were made by the investigators of the first 2
workshops. All authors have cleared this publication, but
there is still controversy on some of the diseases of the
designations of an A, B, or C rating.
We have continued to use the rating system first used in
our 2005 report. This is an arbitrary system. As noted in
encyclopedic references,12there are many rating systems, and
in clinical evidence-based medicine, they are frequently
controversial. We used “A” recommendation to mean strong,
positive studies in the literature. “B” recommendation is
based on positive-controlled studies, but the presence of some
negative studies that did not support the primary outcome.
“C” recommendation is based on some positive studies, but
he first Yale Workshop on Probiotics was convened in
2004. The clinical use of probiotics had gained world-
From the *Section of Digestive Diseases, Yale University School of
Medicine, New Haven, CT; wPediatric Gastroenterology and
Nutrition Unit, Harvard Medical School, Mass. General Hospital
for Children, Charlestown, MA; zDivision of Gastroenterology,
University of Alberta, Alberta, Canada; yDairy and Food Culture
Technologies, Centennial, CO; 8Department of Bacteriology,
University of Dundee, Dundee, Tayside, UK; zRowett Institute
of Nutrition and Health, University of Aberdeen, Aberdeen,
Scotland, UK; #Division of Gastroenterology and Hepatology,
University of North Carolina School of Medicine, Chapel Hill, NC;
**Department of Pediatrics, University of Chicago Comer Chil-
dren’s Hospital, Chicago, IL; wwBeth Israel Deaconess Medical
Center, Harvard Medical School, Boston, MA; and zzDivision of
Gastroenterology, Montefiore Medical Center/AECOM, New
Dr Floch is a consultant to Dannon and Pfizer and a speaker for
Sigmatau and Procter & Gamble. Dr Walker and Dr Madsen
declares no conflict of interest. Dr Sanders has consulted with
numerous food, food ingredient, and dietary supplement companies
over the past 12 months and has received consulting fees or
honoraria for these services. She does not have any royalty,
intellectual property rights, ownership interest (eg, stocks, stock
options or other ownership interest, excluding diversified mutual
funds), or other financial benefit interests in any of these companies.
Dr Macfarlane declares no conflict of interest. Dr Flint declares no
conflict of interest. Dr Dieleman is a consultant for Abbott Canada,
Merck Canada Inc., Ferring and Abbott Nutrition. He has received
research support from Beneo-Orafti. Dr Ringel received research
grants and/or served as consultant and/or participated in advisory-
board and/or speaker for: Danisco, General Mills, Inc., Procter &
Gamble, Salix Pharmaceuticals, Ironwood Pharmaceuticals, Pfizer,
GSK and Smart-Pill. Dr Guandalini declares no conflict of interest.
Dr Kelly declares no conflict of interest. Dr Brandt is a consultant
for Optimer Pharmaceuticals, Inc.
Reprints: Martin H. Floch, MD, Clinical Professor of Medicine, Yale
University School of Medicine, Section of Digestive Diseases, 40
Temple Street, Suite 1A, New Haven, CT 06510 (e-mail: martin.
Copyrightr2011 by Lippincott Williams & Wilkins
S168|www.jcge.comJ Clin Gastroenterol?Volume 45, Supp. 3, November/December 2011
clearly inadequate amount of work to establish certainty.
Where we thought experience was inadequate or there were
too few studies for a reasonable conclusion, we made no
recommendation. This system is similar to those used in
Table 1 is an update of that published in the last
recommendations.2This table includes more clinical con-
ditions and makes recommendations that would affect the
healthy population. Some recommendations not discussed
at this workshop but those made in 2008 are included in the
table. The recommendations for C. Difficile-associated
diarrhea were downgraded from B to B/C by the
information analyzed by Na and Kelly11as compared with
that discussed in 20051and 2008.2The first recommenda-
tion was made for necrotizing enterocolitis particularly
because of the published papers on the subject from
Taiwan in 2008 which were very encouraging and the
strong meta-analysis literature. However, it must be
stressed that if probiotics are used, the strains used in a
specific reference should be followed.13,47Finally, as there
is now clinical evidence that transplanting the entire
intestinal microbiota is beneficial in severe relapsing C.
difficile diarrhea, we have presented that information as
part of our recommendations.14
We would like to emphasize that these recommenda-
tions are based on the literature that is available at this
time. It must also be stressed that these recommendations
are strain specific. Strains are listed in the table for most,
but when not listed, we provide references that can be
consulted for the strain. Anyone using these recommenda-
tions must refer to the reference and the specific strain used
in referenced studies.
TABLE 1. Recommendations for Probiotic Use—Update 2011
Clinical ConditionEffectiveness Specific Strain of Organism and Strain References
Prevention of infection
Prevention of AAD
A Saccharomyces boulardii,15LGG,16Lactobacillus reuteri SD211217 15–18
S. boulardii.19LGG,20combination of Lactobacillus casei DN114 G01,
Lactobacillus bulgaricus, snf Saccharomyces thermophilus21
Prevention of recurrent
Prevention of CDAD
B/CLGG,11S. boulardii22 11,22
A VSL#323–25 23–25
Escherichia coli Nissle27, VSL#328
E. coli Nissle,30VSL#329
E. coli Nissle,31S. boulardii,32LGG33
Bifidobacterium infantis B5624,34,35VSL#334–37,48
Lactobacillus plantarum 299V39
BLactobacillus acidophilus NCDO174813and Bifidobacterium bifidium
Recommendations From 2008*
A LGG, Lactobacillus acidophilus LAFT1, Lactobacillus plantarum,
Bifidobacterium lactis, Lactobacillus johnsonii
Atopic eczema associated
with cow’s milk allergy
LGG, Bifidobacterium lactis41
LGG, B. lactis41
C VSL#3,42L. acidophilus4342,43
Vaginosis and vaginitis
C L. acidophilus,44Lactobacillus rhamnosus GR-1,45L. reuteri RC144644–46
*Check 2008 references for further elaboration on strains used and their availability.
wReference48was made available after the workshop meeting on April 8, 2011 but believed to be significant enough to qualify this probiotic to be in a B
AAD indicates antibiotic-associated diarrhea; CDAD, Clostridium difficile-associated diarrhea; IBD, inflammatory bowel disease; IBS, irritable bowel
syndrome; LGG, Lactobacillus GG.
J Clin Gastroenterol?Volume 45, Supp. 3, November/December 2011 Recommendations For Probiotic Use–2011 Update
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There arenow manypublished meta-analyses
and ratings published and those are referred to in the
articles in this supplement. We hope that this review will be
helpful to clinicians seeking clinical advice on the use of
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