Does Lactobacillus GG prevent antibiotic-associated diarrhea in children?

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Reinoculation and normalization of unbalanced indigenous microflora using specific probiotic strains underlies the rationale behind probiotic administration in children. Probiotic bacteria have been administered both prophylactically and therapeutically in an attempt to modify intestinal activity, as well as mucosal, epithelial and systemic immune activity (1). The most prevalent forms of probiotic bacteria are found in many common fermented foods including yogurt, buttermilk, kefir, tempeh, miso and sauerkraut (2). The two trials of Lactobacillus GG (LGG) for preventing paediatric antibiotic-associated diarrhea (AAD) mentioned in Part I (pages 169, 171) investigate supplemental forms of probiotics (3,4). Because of its safety record, resistance to stomach acid and bile, and ability to temporarily colonize the human intestine almost immediately postadministration, LGG has been the focus of probiotic research (6). There are emerging data to support the safety and effectiveness of LGG (10 to 20 billion colony-forming units/day over a period of 10 days to six months) in reducing paediatric Clostridium difficile colitis, and Crohn’s and AAD (3,4,6–8). The two paediatric LGG trials described in Part I have a number of limitations. The clinical heterogeneity, resulting from differences in the probiotic dose as well as the antibiotic agent administered, was considerable. For example, doses ranging from 10 to 20 billion colony-forming units per day represent a substantial dosing gap. Future trials need to demonstrate the dose that is most effective for infants, children and adolescents. In addition, the authors were not fully explicit in their descriptions of the antibiotic agents used. This makes it difficult to generalize the results to other patient populations using various antibiotic agents for different infections. The potential advantages of probiotic coadministration with antibiotics include ease of administration, the potential for improved compliance (ie, to complete the course of antibiotics as prescribed) and maintenance/restoration of the gut microflora. In Canada, LGG is only sold as a combination product (ie, as part of a cocktail of probiotic strains) (Table 1). There is insufficient evidence on the safety and efficacy of these combination products to warrant recommendation of their coadministration with antibiotics. Although there is some level 1 evidence in adults, further evaluation of the safety and efficacy of LGG in preventing paediatric AAD is needed before routine clinical recommendations can be made. In particular, paediatric trials need to determine the effect of age, dose and antibiotic agent, and need to report on the adverse events, impact on antibiotic compliance and cost benefits. TABLE 1 Probiotic species and subspecies NOT SURE WHAT THE EVIDENCE IS FOR TREATING A PARTICULAR PATIENT PROBLEM? – submit your question to “Evidence for Clinicians” in Paediatrics & Child Health Example of a question: “In patients presenting to the emergency department with mild to moderate croup, are glucocorticoids more effective than placebo in causing clinical improvement?” To promote evidence-based child health among paediatricians, health care workers and trainees, the Cochrane Child Health field is contributing a section titled “Evidence for Clinicians” to Paediatrics & Child Health. You may pose clinical questions that you frequently encounter in the course of practice where you believe there is some controversy. Evidence-based answers for these questions are systematically searched, appraised and summarized along with a description of some of the strengths and weaknesses of the studies. In addition, a clinical expert on the topic will be invited to provide clinical commentary. Specify the type of patient (Population), Intervention, treatment options you are aware of (Comparison) and a clinical result (Outcome) (PICO). You can submit questions online at under the “Evidence for Clinicians” link.