Recommended Uses of Probiotics Containing Bifidobacterium, Lactobacillus, Blautia, and Parabacteroides alistipes
Specific probiotic combinations containing Bifidobacterium and Lactobacillus are primarily recommended for preventing necrotizing enterocolitis in preterm infants and for pouchitis in adults, while there is insufficient evidence to recommend combinations containing Blautia and Parabacteroides alistipes for any clinical condition. 1
Evidence-Based Recommendations by Clinical Condition
Prevention of Necrotizing Enterocolitis (NEC) in Preterm Infants
- Strong evidence supports combinations of Lactobacillus spp. and Bifidobacterium spp. for preventing NEC in preterm infants (less than 37 weeks gestational age) 1
- Specific effective combinations include:
- L. rhamnosus ATCC 53103 and B. longum subsp infantis
- L. casei and B. breve
- L. acidophilus and B. longum subsp infantis
- L. acidophilus and B. bifidum
- L. acidophilus, B. bifidum, B. animalis subsp lactis, and B. longum subsp longum
- These combinations have demonstrated reduced all-cause mortality (OR, 0.56,95% CI, 0.39–0.80) and reduced severe NEC (OR, 0.35; 95% CI, 0.20–0.59) 1
Pouchitis Management
- For adults with pouchitis, an 8-strain combination is suggested:
- L. paracasei subsp paracasei
- L. plantarum
- L. acidophilus
- L. delbrueckii subsp bulgaricus
- B. longum subsp longum
- B. breve
- B. longum subsp infantis
- S. salivarius subsp thermophilus 1
- This recommendation is conditional with very low quality evidence
- Consider cost and feasibility before recommending this combination
Prevention of Clostridioides difficile Infection
- For adults and children on antibiotic treatment, certain probiotics may help prevent C. difficile infection:
- S. boulardii (RR, 0.41; 95% CI, 0.22–0.79)
- 2-strain combination of L. acidophilus CL1285 and L. casei LBC80R (RR, 0.22; 95% CI, 0.11–0.42)
- 3-strain combination of L. acidophilus, L. delbrueckii subsp bulgaricus, and B. bifidum
- 4-strain combination of L. acidophilus, L. delbrueckii subsp bulgaricus, B. bifidum, and S. salivarius subsp thermophilus 1, 2
- Evidence quality is low, and potential harms are inconsistently reported
- Not recommended for immunocompromised patients or those with severe illness due to risk of fungemia 2
Important Clinical Considerations
Strain Specificity
- Probiotic effects are strain-specific - benefits associated with one strain do not necessarily apply to others 3
- Proper identification of specific strains is crucial for clinical efficacy 4
- Typical effective doses range from 10^10-10^11 CFU/day 2
Safety Considerations
- Generally safe in healthy individuals, infants, children, adults, and older patients 5
- Contraindications:
- Separate bacteria-derived probiotics from antibiotics by at least two hours 3
Knowledge Gaps
- No specific evidence supports combinations containing Blautia and Parabacteroides alistipes
- Significant knowledge gaps exist regarding:
- Treatment of C. difficile infection (vs. prevention)
- Irritable bowel syndrome management
- Inflammatory bowel disease (Crohn's disease and ulcerative colitis) 1
- Most clinical trials are small and low-quality, limiting strong recommendations 6
Clinical Algorithm for Probiotic Selection
Identify the specific clinical condition:
- Preterm infant at risk for NEC → Consider Lactobacillus/Bifidobacterium combinations
- Pouchitis → Consider 8-strain combination if feasible
- Antibiotic therapy with C. difficile risk → Consider S. boulardii or specific combinations
- Other conditions → Consider clinical trial participation due to knowledge gaps
Assess patient risk factors:
- Immunocompromised status → Avoid probiotics
- Critically ill → Avoid probiotics
- Central venous catheter → Avoid probiotics
- Otherwise healthy → Proceed with appropriate strain selection
Consider practical factors:
- Cost and availability of specific strain combinations
- Patient preference and ability to adhere to regimen
- Duration of therapy based on clinical indication
The AGA guidelines emphasize that significant research gaps exist in this field, with heterogeneity between studies and variability in probiotic strains. Future high-quality studies are needed to address these knowledge gaps and provide more definitive recommendations 1.