Probiotics

Nancy Toedter Williams

Am J Health Syst Pharm. 2010;67(6):449-458.

Uses

Probiotics have been used for the prevention and treatment of various medical conditions and to support general wellness. Some of their beneficial health effects have been validated, while other uses are supported by limited evidence. Not only are probiotic effects strain specific, probiotic products may vary from each other, and greater benefits may be seen with one lot of probiotics versus another due to the complexity of quality control with live microorganisms. Furthermore, combination agents can make it challenging to quantify particular clinical benefits.^[2,12,13]

Illnesses associated with the gastrointestinal tract have been a common target of probiotics, mainly due to their ability to restore gut flora. The strongest evidence for the use of probiotics lies in the treatment of certain diarrheal diseases, especially rotaviral diarrhea in children. Clinical studies have also supported the role of probiotics in treating pouchitis.^[2,8,9] Data are inconsistent regarding the efficacy of probiotics for antibiotic-associated diarrhea (AAD) and travelers' diarrhea.^[2,8] Although clinical trial results are conflicting, probiotic therapy may also be beneficial in the treatment of Crohn's disease, ulcerative colitis (UC), irritable bowel syndrome (IBS), and Helicobacter pylori infections.^[5,8,14,15] Probiotics have also been shown to decrease the symptoms of lactose intolerance.^[11,15–17]

Other illnesses not associated with the gastrointestinal tract or gut microbiota, including various urogenital problems (e.g., bacterial vaginosis, candidal vaginitis, urinary tract infections), may also respond to probiotics.^[2,6,8,15] Probiotics have also been studied for their role in treating upper respiratory infections (e.g., acute otitis media); reducing the risk of colon and bladder cancer, allergic diseases, and atopy; boosting immune response; and preventing dental caries.^{[2,14,15,17,18]}

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Cite this: Probiotics - Medscape - Mar 15, 2010.

Table 1. Microorganisms Used as Probiotics ^[2,5–7]
Bacteria
Lactobacillus species
L. acidophilus
L. bulgaricus
L. casei
L. crispatus
L. fermentum
L. gasseri
L. johnsonii
L. lactis
L. plantarum
L. reuteri
L. rhamnosus GG
Bifidobacterium species
B. adolescentis
B. animalis
B. bifidum
B. breve
B. infantis
B. lactis
B. longum
Bacillus cereus
Enterococcus faecalisa
Enterococcus faeciuma
Escherichia coli Nissle
Streptococcus thermophilus
Yeast
Saccharomyces boulardii

^a Concerns exist about using enterococci as probiotics because of possible pathogenicity and vancomycin resistance.

Table 2. Probiotic Species and Dosing ^a
Indication and Probiotic	Recommended Dosage Regimen
Acute infectious diarrhea in infants and children
Lactobacillus rhamnosus GG (LGG)	At least 10¹⁰ CFU in 250 mL of oral rehydration solution;^[25] 10¹⁰–10¹¹ CFU twice daily for 2–5 days^[26]
Lactobacillus reuteri	10¹⁰–10¹¹ CFU daily up to 5 days^[26]
Antibiotic-associated diarrhea
Saccharomyces boulardii	4 × 10⁹–2 × 10¹⁰ CFU daily for 1–4 wk^[30]
LGG	6 × 10⁹–4 × 10¹⁰ CFU daily for 1–2 wk^[30]
Lactobacillus acidophilus and Lactobacillus bulgaricus	2 × 10⁹ CFU daily for 5–10 days^[30]
L. acidophilus and Bifidobacterium longum	5 × 10⁹ CFU daily for 7 days^[30]
L. acidophilus and Bifidobacterium lactis	1 × 10¹¹ CFU daily for 21 days^[30]
Clostridium difficile infection
S. boulardii	2 × 10¹⁰ CFU (1 g) daily for 4 wk plus vancomycin and/or metronidazole^[30]
Travelers' diarrhea
LGG	2 × 10⁹ bacteria daily starting 2 days before departure and continued throughout trip^[34]
S. boulardii	5 × 10⁹–2 × 10¹⁰ CFU daily starting 5 days before departure and continued throughout trip^[36]
Irritable bowel syndrome
VSL#3^b	9 × 10¹¹ CFU daily for 8 wk^[38]
Bifidobacterium infantis 35624	10⁶–10¹⁰ CFU daily for 4 wk^[38]
LGG and other organisms	8–9 × 10⁹ CFU daily for 6 mo^[24,38]
Ulcerative colitis (UC)
Escherichia coli Nissle 1917	Active UC: 5 × 10¹⁰ bacteria twice daily until remission (maximum of 12 wk), followed by 5 × 10¹⁰ bacteria daily for a maximum of 12 mo39; inactive UC: 5 × 10¹⁰ bacteria daily (study duration was 12 wk)^[40]
S. boulardii	Active UC: 250 mg 3 times daily for 4 wk plus mesalamine^[42]
VSL#3^b	Active UC: 1.8 × 10¹² bacteria (two 3-g sachets) twice daily for 6 wk plus conventional therapy^[43]
Crohn's disease
S. boulardii	Maintenance therapy: 1 g daily for 6 mo plus mesalamine^[44]
Pouchitis
VSL#3^b	Maintenance therapy: 1.8 × 10¹² bacteria daily, given as 3-g sachets twice daily (study duration was 9 mo)46; maintenance therapy: 1.8 × 10¹² bacteria daily, given as two 3-g sachets once daily (study duration was 12 mo)^[48]
Atopic disease prevention
LGG	10¹⁰ CFU daily for 2–4 wk before expected delivery in pregnant women, followed by infant administration for 6 mo^[50]
Vulvovaginal candidiasis
LGG	10⁹ bacteria per suppository inserted twice daily for 7 days^[54]
L. rhamnosus GR-1 and Lactobacillus fermentum RC-14	At least 10⁹ bacteria suspended in skim milk given orally twice daily for 14 days^[55]

^a CFU = colony-forming units.
^b VSL#3 is a mixture of eight probiotic organisms (Lactobacillus casei, L. plantarum, L. acidophilus, L. bulgaricus, B. longum, Bifidobacterium breve, B. infantis, and Streptococcus thermophilus).

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Probiotics

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