What is the role of Lactobacillus (a type of probiotic) in the treatment of gastroenteritis?

Lactobacillus Treatment for Gastroenteritis

The use of Lactobacillus probiotics is not recommended for the treatment of acute gastroenteritis in North America due to lack of demonstrated benefit in high-quality studies conducted in the United States and Canada. 1

Evidence Assessment

North American vs. International Evidence

• High-quality North American studies show no benefit:

  • Two large, multicenter, randomized, double-blind, placebo-controlled trials in the US and Canada found no benefit of Lactobacillus treatment for acute gastroenteritis 1
  • The US study using L. rhamnosus ATCC 53103 and the Canadian study using L. rhamnosus R0011 and L. helveticus R0052 showed no improvement in moderate-to-severe gastroenteritis compared to placebo 1
  • A specific trial with L. rhamnosus GG in US children showed no difference in outcomes compared to placebo 2

• International studies show mixed results:

  • Studies from India, Italy, Poland, Turkey, and Pakistan have shown some benefit but had one or more concerns regarding risk of bias 1
  • The 2022 Indian observational study of L. rhamnosus GG reported positive outcomes but lacked a control group 3

Strain-Specific Considerations

• Different Lactobacillus strains show varying levels of evidence:
  • L. rhamnosus ATCC 53103: May reduce diarrhea duration (mean 23.13 fewer hours) but with low certainty of evidence 1
  • L. reuteri: May reduce diarrhea duration (mean 24.36 fewer hours) and proportion of children with prolonged diarrhea, but with low certainty of evidence 1
  • L. acidophilus and B. bifidum combination: May reduce diarrhea duration but with low certainty of evidence 1

Clinical Application

Regional Differences Matter

• The American Gastroenterological Association (AGA) specifically notes that differences in host genetics, diet, sanitation, and endemic enteropathogens between North America and other regions affect probiotic efficacy 1
• What works in one geographic region may not work in another due to different causative pathogens and host factors

Potential Pitfalls

• Overreliance on international data: Studies showing benefit were primarily conducted outside North America and may not be applicable to North American populations
• Strain confusion: Different Lactobacillus strains have different effects; they cannot be used interchangeably
• False sense of security: Using probiotics might delay more effective treatments or proper hydration measures

Alternative Approaches

• Focus on evidence-based treatments for gastroenteritis:
  • Oral rehydration therapy remains the cornerstone of treatment
  • Targeted therapies based on specific diagnosis (e.g., loperamide for travelers' diarrhea in appropriate populations) 4

Special Populations

Preterm Infants

• In contrast to gastroenteritis treatment, there is moderate to high-quality evidence supporting the use of certain Lactobacillus strains for preventing necrotizing enterocolitis in preterm, low-birth-weight infants 1
• This represents a different clinical scenario and should not be confused with gastroenteritis treatment

Antibiotic-Associated Diarrhea

• Some evidence supports Lactobacillus GG for preventing antibiotic-associated diarrhea in children 5
• This is distinct from treatment of acute infectious gastroenteritis

Conclusion

Despite some international studies showing modest benefits with certain Lactobacillus strains, the highest quality evidence from North American studies does not support using Lactobacillus probiotics for treating acute gastroenteritis. Regional differences in pathogens, host factors, and environmental conditions likely explain these discrepancies. Current clinical practice should follow the AGA guidelines, which recommend against probiotic use for this indication in North America.