Abstract
Probiotics have been explored in an exponentially increasing number of clinical trials for their health effects. Drawing conclusions from the published literature for the medical practitioner is difficult since rarely more than two clinical trials were conducted with the same probiotic strain against the same medical condition. Consequently, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) made a few recommendations restricting it to probiotic use against acute gastroenteritis and antibiotic-associated diarrhea. Recent studies also made a strong case for probiotic use against sepsis in preterm and term infants from developing countries. Conclusions on the value of probiotics are best based on detailed meta-analyses (MA) of randomized controlled trials (RCT). Outcomes of MA are discussed in the present review for a number of gastroenterology conditions. Since these MA pool data from trials using different probiotic species, large RCT published sometimes come to different conclusions than MA including these studies. This is not necessarily a contradiction but may only mean that the specific probiotic species did not work under the specified conditions. Positive or negative generalization about probiotics and prebiotics should be avoided. Credible effects are those confirmed in independent trials with a specified probiotic strain or chemically defined prebiotic in a specified patient population under the specified treatment conditions. Even distinct technological preparations of the same probiotic strain might affect clinical outcomes if they alter bacterial surface structures. Underpowered clinical trials are another problem in the probiotic field. Data obtained with sophisticated omics technologies, but derived from less than ten human subjects should be interpreted with caution even when published in high impact journals.
Highlights
A recent Cell article reported that eight human volunteers who received probiotics after antibiotic treatment and gut cleansing showed reduced gut microbiota diversity and delayed return to pre-intervention microbiome composition compared with seven controls[25]
This observation was used on the journal’s website to warn against adverse effects of probiotics after antibiotic application. This conclusion ignores data from several studies: of probiotic versus placebo use in nearly 400 mother–child pairs where probiotics corrected undesired microbiota changes caused by antibiotic use or caesarian section[26]; the reduction in IgE-associated allergic diseases in 140 caesariandelivered children treated with probiotics versus controls[27]; and again in a smaller study describing reduced diarrhea in antibiotic-treated Clostridium difficile patients by probiotics[28], where probiotics did not decrease microbial diversity compared with controls[29]
Since antibiotic treatment is a major risk factor for C. difficile infection (CDI) and fecal microbiota transfer is an efficient treatment method, probiotics might be expected to prevent CDI when given as an adjunct to antibiotic treatment
Summary
An MA on probiotics against radiation therapy–induced diarrhea[43], which evaluated six RCTs and 900 patients, found a lower incidence of diarrhea in the probiotic versus the placebo group but without observing a sparing effect on frequency and duration of antidiarrhea medication use and stool consistency. The study showed a significant reduction of lower respiratory tract infections necessitating antibiotic use and of diarrhea, local infections, and omphalitis The authors attributed this striking anti-infectious effect to the superior ability of the probiotic to colonize the infant gut. Synbiotics (successful trials used mostly L. plantarum, L. casei, and B. breve combined with GOS) were the best interventions to reduce pneumonia, urinary infection, sepsis, hospital stay, and antibiotic use but had no effect on mortality[64] These authors concluded that surgeons should consider the use of synbiotics as an adjunctive therapy to prevent post-operative complications. Probiotics might influence the gut–brain axis and influence IBS, mood disorders, and anxiety
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