Probiotics for the Treatment and Prevention of Diarrhoea
Introduction
Probiotics represent a nutritional live microbial supplement that positively affects the
host by enhancing the microbial balance. They work in a number of ways including;
competitive exclusion, production of bacteriocins and lowering of gut pH. Although all
probiotics mechanisms of action are not yet fully understood, it is known that they also
have an effect on immune responses in the gut, which reduces inflammation.(34) The use
of probiotics has been suggested for the prevention and treatment of gut health
problems, including acute infectious diarrhoea, antibiotic associated diarrhoea and
inflammatory bowel disease. Diarrhoea causes an imbalance in the gut microflora,
increased gut permeability and inflammation of the intestine.(36) If probiotic bacteria are
able to adhere to the intestinal epithelium and colonise the gut, then it has been
suggested they can be used to help treat or prevent diarrhoea.
There are multiple studies suggesting that probiotics are effective for the treatment and
prevention of acute non-bloody infectious diarrhoea and antibiotic associated diarrhoea.
(11)
The mechanisms of action have been studied and one method is thought to be due
to the probiotic bacteria interfering with the invasion and adhesion of pathogens.(13) In
addition to stopping bacteria infecting cells already exposed, probiotic bacteria may help
to protect the gut epithelium from further invasion. Lactobacillus rhamnosus has been
shown to have beneficial effects on intestinal immunity, by increasing the numbers of
cells that secrete immunoglobulins in the intestinal mucosa and stimulating the local
release of interferon. (4) Lactobacillus rhamnosus has also been shown to produce an
antimicrobial substance that inhibits the growth of Escherichia coli, Streptococci,
Clostridium difficile, Bacteroides fragilis and Salmonella spp.(5)
To summarise the following mechanisms of action have been documented for probiotics:



Immunomodulation
o Increases the number of intestinal mucosa cells secreting
immunoglobulins
o Facilitates antigen transport to underlying lymphoid cells ensuring a faster
immune reaction to disease causing bacteria
Antibacterial action
o Production of antibacterial substances
o Action against common pathogens including Escherichia coli, Clostridium
difficile and Salmonella spp.
Competitive Exclusion
o Good adhesion to the gut wall, preventing pathogens binding
o Colonisation of the gut with beneficial bacteria
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Probiotics for the treatment and prevention of diarrhoea
June 2005 - This document supersedes all previous document
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1
Types of Probiotic
The most commonly used probiotic bacteria are Lactobacilli, Bifidobacteria and other
lactic acid bacteria, which are species naturally found in the gut. Specific yeast strains
are also sometimes used as probiotics and on an experimental basis other organisms,
not normally part of the microflora, have been used. Probiotic preparations may
contain one bacteria, referred to as monostrain or a number of different bacteria. If
the bacteria are all from the same species eg. a blend of Lactobacillus bulgaricus and
Lactobacillus casei, but are different strains they are known as multistrain probiotics.
However, if the product contains Bifidobacterium longum, Lactobacillus acidophilus and
Streptococcus thermophilus, which are different species of bacteria then it would be
called a multispecies probiotic.
A literature review compared the functionality and efficacy of monostrain, multistrain
and multispecies probiotics.(15) It was found that multispecies probiotics were superior in
treating antibiotic associated diarrhoea in children. It is thought that many probiotic
bacteria work synergistically within the gut enhancing the beneficial effect. For example
different species of probiotic bacteria may be better able to colonise different parts of
the gut, produce antibacterial agents against different pathogens or promote an immune
response. A study on viral gastroenteritis found that multispecies or multistrain probiotic
preparations were able to adhere to the gut during an episode of diarrhoea better than
single strain probiotics.(28)
Probiotic products used in human health care:



Commonly contain Lactobacillus spp., Bifidobacteria spp. and other lactic acid
bacteria
Have different properties and can have synergistic effects
Can contain multistrain and multispecies probiotics, which have been found to be
most effective for diarrhoea
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Childhood Diarrhoea
Diarrhoea is common among children and accounts for substantial amounts of disease
and even death worldwide. In the developing world, children may be particularly
susceptible due to malnutrition, impaired immune status or frequent exposure to
pathogens. However, infectious diarrhoea as well as antibiotic associated diarrhoea is
common in children throughout the world. Young children (under three years of age)
are more susceptible to clinical consequences of infectious diarrhoea and may have the
most to gain from probiotic treatment.
A recent review of nine studies using Lactobacillus spp. found that treatment with this
probiotic reduced the duration of diarrhoeal episodes by an average of 0.7 days and
reduced stool frequency by an average of 1.6 days.(1) It was also noted that some
studies showed a reduction in vomiting in those children given Lactobacillus spp. The
researchers therefore concluded that Lactobacillus spp is a safe and effective treatment
for children with acute infectious diarrhoea. In the review children given probiotics were
all hospital in-patients, in developed countries and received oral rehydration therapy in
addition to probiotics. This treatment was effective in cases where the children had
infectious diarrhoea caused by rotavirus as well as bacterial pathogens.
Patients with diarrhoea are often given a rehydrating solution to drink as part of their
treatment in order to prevent dehydration due to loss of fluid in diarrhoea. Probiotics
can be easily and effectively added to rehydration preparations and given to patients in
the normal way. A literature review found that on average fewer patients taking
probiotics had diarrhoea on the third day after their symptoms started and that the
treatment reduced the duration of the diarrhoea by 30.48 hours.(18) The researchers
therefore concluded that probiotics are a useful addition to rehydration therapy in
treating acute infectious diarrhoea in both adults and children.
A multicenter European trial aimed to evaluate the role of Lactobacillus rhamnosus
administered with oral rehydration therapy, on non-rotaviral diarrhoea.(31) It was
concluded that this kind of treatment for acute diarrhoea results in shorter duration of
diarrhoea and faster discharge from hospital. Using the same administration route a
trial in Italy looked at the treatment of diarrhoea via family paediatricians.(35) The
duration of diarrhoea was recorded for one hundred children, which was reduced from
six to three days in children receiving Lactobacillus rhamnosus.
Rotavirus
Rotavirus is a common cause of diarrhoea amongst children in developing countries.
Several Lactobacillus species have been tested and an effect shown against rotavirus
associated diarrhoea.
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Rotavirus often causes gastro enteritis in hospitalised children but can also cause milder
diarrhoea in children who are cared for in day care centres or similar institutions.
Researchers in Denmark studied the effect of Lactobacillus rhamnosus and Lactobacillus
reuteri on acute diarrhoea in children in day care centres.(24) They found that on
average those receiving the probiotic had diarrhoea which lasted 40 hours less than
those who received the placebo. Interestingly they also found that those children who
received the probiotic less than 60 hours after their diarrhoea had started had a more
pronounced response to the treatment and that the time to recovery was 79 hours
compared to 139 hours, for those who received probiotics later. A similar study with
children in a residential home supplemented milk formula with either Bifidobacterium
spp. alone or with Streptococcus thermophilus to prevent rotavirus infection.(30) Those
infants who received either probiotic supplementation for 8 months showed no signs of
rotavirus infection, whereas 30.4% of the controls had indications of infection.
Lactobacillus rhamnosus and Lactobacillus reuteri were given to children who had been
hospitalised for acute rotavirus associated diarrhoea.(25) The result was an improvement
in their condition and a reduction in the time the virus was excreted. This had the effect
of reducing their stay in hospital, particularly if they started probiotic treatment early in
the diarrhoeal phase. A review of similar studies on the effects of probiotics on
diarrhoea caused by rotavirus in infants and children also found evidence of a clinically
significant benefit of probiotics in the treatment of this acute infection.(26)
In summary research into the use of probiotics in childhood diarrhoea has concluded
that:
 Probiotics are a safe and effective treatment for children with diarrhoea
 Probiotics can be added to rehydration preparations
 Probiotics reduce the duration of diarrhoea and speed recovery
 Probiotic treatment can reduce time spent in hospital
 Probiotics are effective in treatment diarrhoea caused by bacteria pathogens and
Rotavirus
 Probiotics have the greatest effect if given as soon after the onset of diarrhoea
as possible
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Prevention of Infectious Diarrhoea
Infectious diarrhoea occurs more commonly where children have a poor immune status
due to inadequate nutrition or exposure to pathogens. Probiotics could therefore be
useful for improving immunity and preventing infectious diarrhoea. This would then
have the benefit of preventing hospitalisation or reducing outpatient treatment. In
cases where diarrhoea is contacted whilst children are in hospital for another reason,
probiotics could help to prevent secondary infections and reduce their length of stay.
Certain Lactobacillus and Bifidobacteria species have been shown to reduce the risk of
diarrhoeal disease in high risk population groups in both hospital and home
environments.(6-8) A study in undernourished Peruvian children used Lactobacillus
rhamnosus to help control diarrhoea, those receiving the probiotic had significantly
fewer episodes of diarrhoea over a fifteen month period.(33) There was an even greater
decrease in diarrhoeal episodes in younger infants who were not breast fed.
Probiotics can also help to reduce the risk of catching viral gastroenteritis. (2) As well as
rotavirus being a cause of hospitalisation in children it is also often found to cause
gastroenteritis in those admitted for other reasons. A Polish study showed that the use
of Lactobacillus rhamnosus significantly reduced the risk of rotavirus gastroenteritis.
Only 6.7% of patients given the probiotic had diarrhoea compared to 33.3% of the
controls.(27) Even during episodes of diarrhoea probiotic strains of bacteria showed good
adhesion in the gut, therefore helping to maintain the beneficial gut flora during the
infection and aiding recovery.(28)
Breast fed babies have Bifidobacteria as the prevalent species in their colonic flora,
which is thought to offer some protection against diarrhoea. A trial in France added a
Bifidobacterium to a milk formula, which was given to babies under 8 months of age,
who were in residential care where they were unable to receive any of the nutritional
benefits of breast milk.(20) The incidence of diarrhoea in these infants was 28.3% in the
probiotic supplemented group compared to 38.7% in the control, there was also a trend
for shorter episodes of diarrhoea in those receiving the bifidobacterium.
The benefits of using probiotics to prevent infectious diarrhoea are:
 Preventing hospitalisation
 Reducing outpatient treatment for diarrhoea
 Protecting malnourished or immunocompromised children
 Reducing infection with pathogenic bacteria and viruses
 Improving the microflora of infants who are not breast fed
 Can be easily and effectively added to milk formula
 Preventing secondary infection in hospitals
 Reducing the transmission of infection in children cared for in a group setting
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Antibiotic associated diarrhoea
Twenty percent of people who take a course of antibiotics suffer from diarrhoea. As well
as being an unpleasant side effect, it can in some cases, lead to chronic or persistent
diarrhoea. Antibiotics are taken for a variety of bacterial infection in order to kill the
bacteria and prevent disease. However, as the same time as killing pathogenic bacteria
they may also kill the beneficial bacteria within the gut. This effect will vary depending
on the type of antibiotic used as well as differences in patients.
A reduction in the number of beneficial bacteria in the gut causes an imbalance in the
microflora and can allow pathogenic species to increase. The gastrointestinal microflora
is less able to resist colonisation by pathogenic species, which causes clinical symptoms,
most commonly diarrhoea. The severity of antibiotic associated diarrhoea may range
from a brief episode of diarrhoea to a more serious condition with symptoms such as
electrolyte disturbances, dehydration, cramping abdominal pain and toxicity. Probiotics
are used to treat or prevent antibiotic associated diarrhoea because they replace the
beneficial bacteria which are lost during antibiotic therapy. This in turn helps to prevent
colonisation of pathogens, which can cause diarrhoea. Other methods by which
probiotics reduce diarrhoea are thought to be due to the production of antimicrobial
substances, competition for nutrients and stimulation of intestinal immune responses.
Diarrhoea is a common complication of antibiotic therapy given to children, especially if
broad-spectrum agents are used. Lactobacillus rhamnosus has been shown to reduce
the risk of antibiotic associated diarrhoea by approximately 75% in children.(9) The same
probiotic bacteria was used in an American trial using outpatients receiving antibiotics
for various acute infections.(32) They similarly found a significant reduction in stool
frequency and increased stool consistency in children receiving probiotics compared with
the placebo group. In another study children being treated for respiratory infections
with antibiotics, were given either a placebo or Lactobacillus rhamnosus during the
course of medication. The incidence of diarrhoea was 5% in the Lactobacillus group and
16% in the placebo group.(10) Another study in children found that those patients who
received a probiotic along with a broad spectrum antibiotic had forty three percent fewer
diarrhoeal episodes, than those who did not.(23) A meta-analysis of studies on antibiotic
diarrhoea concluded that probiotics, particularly Lactobacilli species, could be used to
prevent this condition. (3)
Clostridium difficile
It is estimated that 25% of cases of antibiotic associated diarrhoea are caused by
Clostridium difficile. Infection with this pathogen can lead to colitis and is a common
complication of antibiotic therapy. This problem is becoming increasingly prevalent in
hospital inpatients, particularly the elderly. Probiotics have been shown to prevent
Clostridium difficile infection, after the use of antibiotics. The probiotic strain
Lactobacillus rhamnosus has been used in the prevention of relapsing Clostridium
difficile diarrhoea, associated with antibiotic use.
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In a trial, elderly patients receiving antibiotics were also given either a placebo or a
probiotic containing Lactobacillus and bifidobacterium.(12) Stool samples from all patients
were analysed for Clostridium difficle toxins, which were found in 78% of the control
group and 46% of the probiotic group. This means that the probiotic was reducing the
numbers of this pathogen and the production of toxins. It is these toxins which cause
inflammation within the gut, leading to colitis. A review of studies using a probiotic
yeast Saccharomyces boulardii also concluded that it was also a safe effective
preventative for this major side effect of antibiotics.(29)
Benefit of Prebiotics
Prebiotics are non-digestible food ingredients that are used preferentially by beneficial
bacteria as a food source. This in turn selectively increases the growth and or activity of
particular bacteria within the colon. In other words prebiotics are food for the beneficial
bacteria within the gut, in this way they complement probiotic bacteria and strengthen
their effect. Products containing both probiotics and prebiotics are called synbiotics due
to the synergistic effect these ingredients have within the gut.
A trial introducing Bifidobacterium lactis and the prebiotic, galacto-oligosaccharide to
milk for young children found that there was a significant reduction in bloody diarrhoea
and a non significant 10% reduction in all diarrhoea.(16) In another study children
receiving antibiotic treatment were given a nutritional supplement with or without a
synbiotic.(19) The patients who received the synbiotic with their medication gained more
weight and had significantly less bacterial illness after 14 days.
Benefits have also been found using probiotics and prebiotics, to prevent antibiotics
associated diarrhoea in children. An Italian trial found that when FOS
(fructooligosaccharide) and Lactobacillus sporogens were given at the same time as
antibiotic therapy only 38% of patients had diarrhoea compared to 71% of the children
who received a placebo.(21) There was also a significant reduction in the duration of the
diarrhoea in those children who received the synbiotic, 0.7 compared to 1.6 days.
Synbiotics are thought to shorten the course of diarrhoea by promoting a rapid
improvement in stool formation and reduction stool frequency.
Synbiotic preparations have many benefits in the prevention and treatment of diarrhoea:
•
•
•
•
•
•
Prebiotics are a food source for beneficial bacteria
Prebiotics enhance the effects of probiotics
Synbiotics are effective in preventing infectious diarrhoea
Synbiotics can also be used to prevent antibiotic associated diarrhoea
Synbiotics have been shown to reduce the duration of diarrhoea
Synbiotics improve stool formation and reduce stool frequency
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Probiotics International Ltd., Matts Lane, Stoke sub Hamdon, Somerset, TA14 6QE
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7
Conclusion
The use of probiotics has been studied for the treatment and prevention of diarrhoea
with a variety of causes;
•
•
•
•
•
•
•
•
•
For treatment of diarrhoea probiotics work well if added to oral rehydration
solutions.
Probiotics can be used in the treatment of diarrhoea caused by bacteria and
rotavirus
Probiotics are also effective in the prevention of acute infectious diarrhoea
If taken at the same time as antibiotic therapy probiotics are effective as a
preventative for antibiotic associated diarrhoea
Probiotics are useful in the control of diarrhoea caused by Clostridium difficle
Those who suffer from chronic or persistent diarrhoea may benefit from taking
probiotics to reduce symptoms
People who travel, particularly to high risk countries, could take probiotics to
prevent diarrhoea
Multistrain and multispecies probiotics offer more mechanisms of action within
the gut and have been shown to be more effective at treating diarrhoea
Prebiotics work well in combination with probiotics to reduce diarrhoea.
Research trials suggest that probiotics offer a safe and effective treatment for children
with acute infectious diarrhoea. Documented beneficial effects of probiotics on
diarrhoea include:







Reduces duration of diarrhoeal episodes
Reduces stool frequency
Reduces vomiting
Reduces risk of diarrhoea
Faster discharge from hospital
Shorter recovery time
Reduces period of pathogen excretion
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Probiotics for the treatment and prevention of diarrhoea
June 2005 - This document supersedes all previous document
Probiotics International Ltd., Matts Lane, Stoke sub Hamdon, Somerset, TA14 6QE
www.protexin.com
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