PREBIOTICS AND PROBIOTICS
Prof. Dr. R.V.S.N. Sarma,
MD., M.Sc (Canada), RCGP, FCGP, FIMSA,
Senior Consultant Physician,
Cardio-Metabolic and Chest Specialist
Honorary National Professor of Medicine (CGP)
visit: www.drsarma.in
www.youtube.com/user/drsarmaji
Antibotics
Probiotics
Prebiotics
Synbiotics
2
LOUIS PASTEUR
(1822 - 1895)
Potential benefits of
Lactobacillus~125 yrs ago
METCHNIKOFF ELIE
(1848-1916)
1905: Concept of Probiotics
3
COLONIZATION OF GUT

Starts immediately after birth
 Place of birth
 Type of Delivery
 Feeding: Time, Type
 Pre-lacteals vs Exclusive breast feed.
 Premature vs. Full term
 Sick babies
4
COLONIZATION OF GUT

1st Year;: > 200 bacterial species

Adult : 500-600 bacterial species

Elderly: 300 Bact. Species

Chr. Intestinal disorders
5
RELATIVE PROPORTION

For context – Total Cells
 Theirs ~ 100,000 billion.
 Ours ~ 10,000 billion.
GUT FLORA IN
BREAST FED VS
FORMULA FED BABIES
7
Friendly bacteria
Unfriendly / harmful Bacteria
– Probiotics
– Pathogens
COMMON FLORA
Facultative Anaerobes
Staph. Aureus, albus
Strict anaerobes
Nose & skin
Mouth, Colon, Vagina
Lactobacilus Sp, Bifidobact..
Candida albicans
Mouth, Colon, Vagina
Vagina, Outer urethra
E. Coli.
Haemophilus Sp.
Nasophyrinx & Conjunctiva
Pseudomonas aeruginosa
Colon & skin
LACTOBACILLUS: BIFIDOBACTERIA: SACCHAROMYECES:
9
PROBIOTICS ( “FOR LIFE’’)
Probiotics
(Friendly Bacteria)
Normalise
Intestine
Suppression of
PPMs
Immunomodulation
Strengthens
immunity
Metabolic effects
Production of vitamins;
improves digestion
Intestinal
mucosal integrity
Alleviate
food allergy symptoms
Lactose tolerance
Regulation of
bowel movement
IBS
Conrol of IBD
Lowers cholesterol
(Bile acid deconjugation
&Secretion)
MECHANISM OF ACTION
Inhibit Potentially Pathogenic Microorganisms (PPMs)

Reduction in Intestinal pH ( through production of SCFAs)

Production of bacteriocins

Competitive blocking of adhesion sites

Competition for nutrients
MOA OF PROBIOTICS
TYPES OF PROBIOTICS

Most abundant Probiotic in GI

Lactobacillus:


Acidophilus,

Rhamnosus, GG

Plantarum,

Reuteri,

Bulgaricus,

Sporogens

Casei
Action only in Small intestine
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TYPES OF PROBIOTICS

Bifidobacteria

32 different species : Longum, Bifidum, infantis etc

Most abundant probiotic next to lactobacilli Sp. in the GIT

Action : Large Intestine
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UNIQUENESS OF BIFIDOBACTERIA

Apart from the general Probiotics effect ,

Bifidobacteria helps is Glutamine synthesis

Glutamine helps in maintaining the mucosal integrity

NH3 + Glutamic acid ------------> Glutamine
Bifidobacteria
TYPES OF PROBIOTICS
SACCHAROMYCES BOULARDII

Saccharomyeces:

Boullardii,

Salivarium,

Thermophilus

Non colonising yeast – so needs
repeated readministration

Action in large intestine
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IDEAL PROPERTIES OF A PROBIOTIC
1. Be nonpathogenic and nontoxic to the host
2. Be antagonistic to pathogens
3. Exert a beneficial effect on the host
4. Capable of surviving, colonizing and proliferating in the
gut (should not be killed by gastric juice / bile acids)
5. Able to inhabit in the S & L intestine
6. Must be of human origin
7. Contain a large number of viable cells and remain viable
during storage and use
IS PROBIOTIC PREPN WITH
BIFIDOBACTERIA USEFUL ?

Bifidobacteria is an Important Probiotic as it maintains the
mucosal integrity

Hence Bifidobacteria supplementation is useful in conditions
like Gastroenteritis where the GI mucosa is severely damaged

However, all the marketed preparation contains only 1 – 3
species of Bifidobacteria as against 32 required

Hence it is ideal to supplement with probiotic which give
nutrient to Bifidobacteria so all 32 species can proliferate
PREBIOTICS
• Non-digestible dietary supplements, which provide
‘’nutrition’’ for Probiotics
• Oligosaccharides (fructo-oligosaccharides or FOS),
Inulin, Lactulose, Lactitol
• Mutated Bacterial Species (Streptococcus faecalis,
Clostridium butyricum, Bacillus mesentericus)
• Advantage of Prebiotics in bacterial form : Addl.
Probiotic activity ( Intrinsic Probiotic activity)
PREBIOTICS – IDEAL CHARACTERS
Supply nutrient to beneficial bacteria
Should escape digestion in the stomach and reach
Intestine
Should promote the proliferation of beneficial
bacteria (Lactiobaccillus , Bifidobacteria)
PREBIOTICS & PROBIOTICS :
IS THERE ANY DIFFERENCE ?
Probiotics
Prebiotics
Nature of Microorganism
the Prep
Food supplement
(eg: FOS) or Microorganism
(eg : S.F )
Prime Fn To kill harmful
pathogen
To supply nutrition
(Killing the pathogen is an
additional effect)
PREBIOTICS – WHICH IS BETTER ?
FOS OR LIVE MUTATED BACTERIA ?

FOS – Recommended daily dose is 2 - 6 gm

Marketed prep. offer 100, 250 mg of FOS –
Which is inadequate dose

Also at high dose , FOS cause flatulence and GI discomfort

Hence using a live mutated bacteria is beneficial as it would
ensure the continuous colony count (nutrient) with out any
side effect
PRE/PROBIOTICS - INDICATIONS
1. Infective diarrhea (viral, bacterial)
2. Antibiotic associated diarrhea
3. Lactose intolerance
4. Recurrent aphthous ulcers and stomatitis
5. Travelers’ diarrhea
6. Inflammatory IBD (Ulcerative colitis, Crohn’s)
7. Irritable bowel syndrome
8. Post operative state
9. Pouchitis
10. Diverticular disease of colon
INFECTIOUS DIARRHEA

Due to bacteria, Virus or Protozoa

Viral diarrhoea :
 Rotavirus
 Mx : ORS / Infusion

Bacterial Diarrhoea :
 E.coli , Salmonella , Shigella , V. Cholerae
 Mx : Antibacerial

Protozoal Diarrhoea :
 E.Histolytics
 Mx : Metrinadozole

An all the 3 types , there is a disturbance of the Intestinal microflora. Hence
supplementation with Bifilac normalises the gut flora by displacing the PPMs
and hence reduce the duration of diarrhoea
PROBIOTICS IN PREVENTION AND
TREATMENT OF DIARRHEA
PURPORTED MECHANISMS OF ACTION
Free amino acids
Neutralization of
Organic acids
dietary carcinogens
β-Galactosidase activity
Oligosaccharides
Probiotics
Immunostimulatory
Cholesterol assimilation
Antioxidant
Short chain fatty acids
Survival and adhesion
Bioactive peptides
Bacteriocin
competitions with
pathogenic bacteria
Adhesive
Non-adhesive
Microorganisms
M = M cells of intestinal epithelium
L = Lymphocytes
Immune Response
APC = Antigen presenting cells
Intestinal Epithelium
Th = T-helper cells
M
IL = Interleukines
TGF = Tumour growth factor
L
IFN = Interferon
TNF = Tumour necrosis factor
L
L
APC
Ig = Immunoglobulin
L
Th0
IgG ↑
Cell
mediated
response
IL-2 ↑
IFN- γ ↑
+
TGF-β↓
IL-4 ↓
IL-10 ↓
B
Antibody
mediated
response
IgM ↑
IgE ↓
B
Th2
Th1
IgA
IL-2 ↑
IFN-γ ↑
TNF-α ↑
IFN-α ↑
Natural killer cells ↑
Macrophages ↑
Cytotoxic T-lymphocytes ↑
Viruses
Tumors
POTENTIAL MECHANISMS OF PROBIOTICS FOR
PREVENTION OR TREATMENT OF DIARRHEA

Protection of intestinal epithelial barrier function

Regulation of intestinal epithelial homeostasis

Regulation of intestinal microbial environment

Modifications to commensal and probiotic bacteria to
enhance diarrhea prevention
ANTIBIOTIC ASSOCIATED DIARRHEA
 Most common antibiotics that cause diarrhea
 Alteration in composition of normal intestinal bacterial micro
flora by antibiotic makes the GI tract susceptible to infection
by fungus (Candida) or bacteria, Clostridium difficile
 Fungus alters absorptive surface of GI tract – diarrhea
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PROBIOTICS DECREASE ADD
Pseudomembranous Colitis
Volcano lesions in AAD
•Relative risk of diarrhea reduced by 40 %. By LGG / Saccharomyces
•5-10 billion viable organisms X 3-4 times/day
•Probiotics to be separated from Antibiotics by couple of Hours
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• The incidence of AAD can go up to 26% of patients on
antibiotics,
• Broad-spectrum antibiotics are associated with the
highest rate of AAD because of their disruptive impact on
the normal intestinal flora.
HIGHEST RISK OF AAD…
Almost all antibiotics, particularly those that act on anaerobes, can cause
diarrhea, but the risk is higher with aminopenicillins, a combination of
aminopenicillins and clavulanate, cephalosporin's, and clindamycin.
Diarrhea is a common adverse effect of antibiotic treatments.
Antibiotic associated diarrhea occurs in about 5-30% of patients
BMJ 2002;324:1345-1346 (8 JUNE)
PROBIOTICS DECREASE DIARRHEA
International Microbiology 2004 ; Mar 7(1) 59-62
CLOSTRIDIUM DIFFICILE ASSOCIATED DIARRHEA (CDAD)
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CLOSTRIDIUM DIFFICILE ASSOCIATED DIARRHEA (CDAD)
36
LACTOSE INTOLERANCE
 Lactase digests lactose commonly present in milk and milk
products.
 Lactose is not digested when there is a deficiency in lactase
and results in diarrhea.
 Supplementation with probiotics has been shown to mitigate
the symptoms of lactose intolerance.
RECURRENT APHTHOUS ULCERS / STOMATITIS
Superficial ulcers or fissures in
mucosa of mouth.
Painful condition.
Each episode lasts 8 -14 days.
Exact etiology not known.
Stress appears to play a role.
Mx : B complex / multivitamin,
probiotics and antiseptic or
tetracycline mouth wash.
TRAVELER’S DIARRHEA
Transmission of infection:
Feco-oral route / fingers and flies.
Affects tourists traveling ; Shigella
Travelers’ diarrhea can be prevented by regular prophylactic
intake of beneficial bacteria
One week before travel, during travel, one week after
completion of travel.
IBS – IRRITABLE BOWEL SYNDROME

Chronic medical condition characterized by abdominal pain,
discomfort and results in change in the bowel frequency &
consistency in the stools

Cause : Alteration in the bowel motility & transit ( due to anxiety)

Symptoms : Bloating , gas , dyspepsia , constipation, diarrhea ,
diarrhea alternating with constipation, dysentery
IBD – INFLAMMATORY BOWEL DISEASE

Inflammation in GI Tract
Crohn’s Disease
Ulcerative Colitis
Small & Large intestine
Large intestine (Rectum & Colon)
Crohn’s disease
Ulcerative colitis
IBD – INFLAMMATORY BOWEL DISEASE

Symptom : Diarrhoea / Dysentery / fever / Wt.loss

Rx : Sulphasalazine , Steroids , Immuno-suppresants

Rationale for Probiotic : IBD patients have a compromised
bowel flora due to inflammation. Supplementation with
probiotic helps to normalize the bowel flora and there by
reduces the inflammation

Probiotics promotes the antigen specific IgA immune
response and shortens the diarrheal phase .
Also reduces the relapse rate
POUCHITIS
Inflammation of an internal pouch created in patients who
have part of their colon removed to treat ulcerative colitis
Why Probiotics : Low levels of bacterial flora in intestine
DIVERTICULITIS
Diverticula - Formation of small bulges / bags in the colon
 Diverticulitis – Inflammation/ Infection in the diverticula
SYMBIOTIC

Mixture of Pre and Probiotic

Probiotics – Helps in reducing the PPMs

Prebiotics – Helps in Providing food for Probiotics
BIFILAC

Lactobacillus sporogenes
50 million ( Probiotic)

Streptococcus faecalis T-110
30 million ( Prebiotic)

Clostridium butyricum TO-A
2 million ( Prebiotic)

Bacillus mesentericus TO-A
1 million ( Prebiotic)
PREBIOTICS IN BIFILAC

Streptococcus faecalis T-110
30 million ( Prebiotic)

Clostridium butyricum TO-A
2 million ( Prebiotic)

Bacillus mesentericus TO-A
1 million ( Prebiotic)
PREBIOTICS – HOW DO THEY GET FOOD ?
On ingestion, 3 mutated
Streptococcus
faecalis
( Small )
live bacteria continue to
proliferate in the GI tract
by a process of
Symbiosis
Symbiosis : Biological
association of two or
Clostridium
Butyricim
( Small & Large)
Bacillus
Mesentricus
( Small)
more species to their
mutual benefit.
THANK YOU ALL