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Probiotics and Prebiotics

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

Introduction1

  • Probiotics may be defined as a preparation of, or a product containing, viable, defined microorganisms in sufficient numbers, which alter the microflora (by implantation or colonisation) in a compartment of the host. The major source of probiotics for humans is dairy-based foods containing intestinal species of Lactobacillus or Bifidobacterium.The most common type used is Lactobacillus acidophilus (also known as one of the 'friendly bacteria'), a species of Gram-positive, rod-shaped bacteria often found in the intestinal tract of humans and animals, the human mouth and vagina. It is an anaerobic organism that produces lactic acid which reduces the pH. This may have an inhibitory effect on other organisms, especially candida.
  • Prebiotics, in contrast, are non-digestible carbohydrates (mainly oligosaccharides and non-starch polysaccharides) which act by promoting the growth and/or activity of probiotic bacteria in the gut. The most common are fructo-oligosaccharides (FOS), inulin and galacto-oligosaccharides. They are found in various vegetables and fruit such as tomatoes, asparagus and bananas. Prebiotics are relatively stable and, unlike probiotics, can be relied on to arrive relatively unchanged in the gut despite the presence of digestive enzymes. They are usually given in combination with probiotics but there is some evidence that they have independent benefit in some conditions (e.g. colitis).2,3
  • Symbiotics contain prebiotics and probiotics in the same preparation.

Uses of probiotics

Many commercially available products (e.g. yoghurt) are classed as foodstuffs. This means that they escape the rigorous testing for efficacy which is applied to medicines. They have biologically plausible modes of potential action as displacers of pathogens, immunomodulators or local antimicrobial agent secretors. Initial scientific investigation indicates some evidence of usefulness of probiotics in some areas and a definite impetus to continue research into their effects.4

Gastrointestinal disorders

  • Prophylaxis of antibiotic-associated diarrhoea (but no convincing evidence that probiotics are useful as treatment once diarrhoea is established).5
  • Prevention of traveller's diarrhoea.6
  • Recurrence of Clostridium difficile diarrhoea.7
  • Induction of remission in Crohn's disease - evidence equivocal - further research is needed.8
  • Maintaining remission in ulcerative colitis- likely to be of benefit but further research is needed.9
  • Pouchitis in patients who have undergone surgical resection - probiotic VSL#3® (4 Lactobacillus spp. strains, 3 Bifidobacterium spp. strains and Streptococcus salivarius (thermophilus)) shown to be effective in preventing a first attack after surgery and in maintaining remission;10,11 however, effectiveness during acute attack is less certain.12
  • Irritable bowel syndrome - the National Institute for Health and Clinical Excellence (NICE) recommends that if patients wish to try probiotics they should take them at a dose recommended by the manufacturer for a minimum of four weeks.13
  • Eradication of Helicobacter pylori - a meta-analysis concluded that fermented milk-based probiotic preparations increased eradication rates in patients on standard eradication therapy by 5-15%.14
  • Treatment of acute infectious diarrhoea in children - probiotics reduce recovery time by about one day.15 They are also useful in adults but further investigation is needed to decide on useful bacterial strains and regimens.16
  • Necrotising enterocolitis - probiotic therapy reduced both the incidence and severity of this condition in a study of very low birthweight infants.17

Evidence of ineffectiveness

  • Great claims have been made for probiotics for a variety of conditions. It may be helpful for GPs to be aware of conditions in which the evidence-base is weak or lacking:
  • Boosting the immune system in children18
  • Prevention of allergic disease19
  • Chronic rhinosinusitis20
  • Prevention of urogenital infection21

Cautions/contra-indications/common problems

A meta-analysis of trials using probiotics for the treatment of gastroenteritis did not report any adverse effects and probiotics are considered to be relatively safe in most patient groups.22,23 Reports of adverse effects in trials are of limited value and there is currently much debate about how such effects can be monitored.24 There have, however, been reports of severe infections in debilitated or immunocompromised patients, so their use would not be recommended in these groups.25,26

Future research

There is no doubt that prebiotics and probiotics are an interesting group that warrant further investigation. Guidelines for research into their risks and benefits, dosage regimes and interaction with other medication have recently been published.27

Document references

  1. Schrezenmeir J, de Vrese M; Probiotics, prebiotics, and synbiotics--approaching a definition. Am J Clin Nutr. 2001 Feb;73(2 Suppl):361S-364S. [abstract]
  2. Probiotics and Prebiotics; The Environmental Illness Resource 2010.
  3. Probiotics and Prebiotics - Practice Guidelines; World Gastroenterology Organisation 2008.
  4. Rioux KP, Fedorak RN; Probiotics in the treatment of inflammatory bowel disease. J Clin Gastroenterol. 2006 Mar;40(3):260-3. [abstract]
  5. D'Souza AL, Rajkumar C, Cooke J, et al; Probiotics in prevention of antibiotic associated diarrhoea: meta-analysis. BMJ. 2002 Jun 8;324(7350):1361. [abstract]
  6. Pham M, Lemberg DA, Day AS; Probiotics: sorting the evidence from the myths. Med J Aust. 2008 Mar 3;188(5):304-8. [abstract]
  7. Plummer S, Weaver MA, Harris JC, et al; Clostridium difficile pilot study: effects of probiotic supplementation on the incidence of C. difficile diarrhoea. Int Microbiol. 2004 Mar;7(1):59-62. [abstract]
  8. Butterworth AD, Thomas AG, Akobeng AK; Probiotics for induction of remission in Crohn's disease. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006634. [abstract]
  9. Do VT, Baird BG, Kockler DR; Probiotics for Maintaining Remission of Ulcerative Colitis in Adults (March). Ann Pharmacother. 2010 Feb 2. [abstract]
  10. No authors listed; Probiotics for gastrointestinal disorders. Drug Ther Bull. 2004 Nov;42(11):85-8. [abstract]
  11. Sandborn W, McLeod R, Jewell D; Pharmacotherapy for inducing and maintaining remission in pouchitis. Cochrane Database Syst Rev. 2000;(2):CD001176. [abstract]
  12. Elahi B, Nikfar S, Derakhshani S, et al; On the benefit of probiotics in the management of pouchitis in patients underwent ileal pouch anal anastomosis: a meta-analysis of controlled clinical trials. Dig Dis Sci. 2008 May;53(5):1278-84. Epub 2007 Oct 17. [abstract]
  13. Irritable bowel syndrome, NICE Clinical Guideline (February 2008); Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care
  14. Sachdeva A, Nagpal J; Effect of fermented milk-based probiotic preparations on Helicobacter pylori Eur J Gastroenterol Hepatol. 2009 Jan;21(1):45-53. [abstract]
  15. Chen CC, Kong MS, Lai MW, et al; Probiotics have clinical, microbiologic, and immunologic efficacy in acute Pediatr Infect Dis J. 2010 Feb;29(2):135-8. [abstract]
  16. Allen SJ, Okoko B, Martinez E, et al; Probiotics for treating infectious diarrhoea. Cochrane Database Syst Rev. 2004;(2):CD003048. [abstract]
  17. Lin HC, Su BH, Chen AC, et al; Oral probiotics reduce the incidence and severity of necrotizing enterocolitis in very low birth weight infants. Pediatrics. 2005 Jan;115(1):1-4. [abstract]
  18. Perez N, Iannicelli JC, Girard-Bosch C, et al; Effect of probiotic supplementation on immunoglobulins, isoagglutinins and Eur J Nutr. 2009 Oct 17. [abstract]
  19. Kopp MV, Salfeld P; Probiotics and prevention of allergic disease. Curr Opin Clin Nutr Metab Care. 2009 May;12(3):298-303. [abstract]
  20. Mukerji SS, Pynnonen MA, Kim HM, et al; Probiotics as adjunctive treatment for chronic rhinosinusitis: a randomized Otolaryngol Head Neck Surg. 2009 Feb;140(2):202-8. [abstract]
  21. Abad CL, Safdar N; The role of lactobacillus probiotics in the treatment or prevention of urogenital J Chemother. 2009 Jun;21(3):243-52. [abstract]
  22. Johnston BC, Supina AL, Vohra S; Probiotics for pediatric antibiotic-associated diarrhea: a meta-analysis of randomized placebo-controlled trials. CMAJ. 2006 Aug 15;175(4):377-83. [abstract]
  23. Salminen S, von Wright A, Morelli L, et al; Demonstration of safety of probiotics -- a review. Int J Food Microbiol. 1998 Oct 20;44(1-2):93-106. [abstract]
  24. Donohue DC; Safety of probiotics. Asia Pac J Clin Nutr. 2006;15(4):563-9. [abstract]
  25. Oggioni MR, Pozzi G, Valensin PE, et al; Recurrent septicemia in an immunocompromised patient due to probiotic strains of Bacillus subtilis. J Clin Microbiol. 1998 Jan;36(1):325-6.
  26. Orrett FA; Fatal Bacillus cereus bacteremia in a patient with diabetes. J Natl Med Assoc. 2000 Apr;92(4):206-8. [abstract]
  27. Rijkers GT, Bengmark S, Enck P, et al; Guidance for Substantiating the Evidence for Beneficial Effects of Probiotics: J Nutr. 2010 Feb 3. [abstract]

Acknowledgements

EMIS is grateful to Dr Laurence Knott for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2010.
Document ID: 446
Document Version: 4
Document Reference: bgp24941
Last Updated: 6 Apr 2010
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