Antibiotics and Probiotics in Inflammatory Bowel Disease: Why, When, and How

Cosimo Prantera; Maria Lia Scribano

Disclosures

Curr Opin Gastroenterol. 2009;25(4):329-333. 

In This Article

Probiotics

Probiotics are defined as a living microbial food ingredient with a beneficial effect on human health.[32] However, it is wise to treat with scientific scepticism the claim that they are useful in many pathological conditions as a long elixir of life. Like other natural remedies considered free of side effects, probiotics have attracted the consumer's favour, possibly biasing medical criticism. However, to do them justice, they have been successfully employed for the treatment of acute diarrhoeal illnesses and in prevention of antibiotic-related diarrhoea.[33,34] A previous Cochrane review on the efficacy of probiotics in maintenance of Crohn's disease remission failed to show any beneficial effect.[35] The authors concluded that, on account of the small number of the patients enrolled in these trials, the analysis could not have the statistical power to eventually detect a difference.

A recent meta-analysis confirmed that probiotics do not seem to be a therapeutic option for maintenance of Crohn's disease remission.[36] Last year a Cochrane systematic review of randomized controlled trials comparing probiotics against placebo or any other intervention for induction of remission in Crohn's disease included only one study with only 11 patients.[37] Another Cochrane study reviewed the role of probiotics in inducing remission in ulcerative colitis.[38] Four studies were analysed for a total of 244 patients. The conclusion was that adding probiotics to conventional treatment did not improve the overall remission rates in mild to moderate ulcerative colitis, but it was possible to obtain a slight benefit in decreasing the disease activity. The only advantage of probiotics in IBD has been registered with VSL#3, a combination of four Lactobacillus species, three Bifidobacterium species, and 1 Streptococcus salivarius species, for treatment and prevention of pouchitis, as shown in two small trials published between 2000 and 2003.[39] ECCO consensus suggests that E. coli Nissle 1917 could be useful as alternative therapy to mesalazine in ulcerative colitis.[25•] Another meta-analysis concluded that, despite many methodological differences and a significant heterogeneity of studies, probiotics do not differ significantly from anti-inflammatory drugs for efficacy and safety in achieving ulcerative colitis remission.[40] In spite of this optimistic conclusion our point of view is that the use of probiotics in IBD cannot be recommended.[41] The published trials have employed diverse bacterial strains with various bacterial contents in different clinical situations and, more critically still, few patients have been enrolled in these studies. More randomized trials with strict enrolment criteria are needed before accepting probiotics in the therapeutic armamentarium of IBD.

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