Can Lactobacillus (a type of probiotic) help with diarrhea?

Lactobacillus for Diarrhea: Evidence-Based Recommendations

Specific Lactobacillus strains can effectively reduce the duration and severity of diarrhea, particularly in antibiotic-associated and acute infectious diarrhea, with Saccharomyces boulardii and Lactobacillus rhamnosus GG showing the strongest evidence of efficacy. 1

Efficacy of Lactobacillus in Different Types of Diarrhea

Antibiotic-Associated Diarrhea

• The American Gastroenterological Association (AGA) suggests using specific probiotics for prevention of antibiotic-associated diarrhea: 2

  • Saccharomyces boulardii
  • The 2-strain combination of L. acidophilus CL1285 and L. casei LBC80R
  • The 3-strain combination of L. acidophilus, L. delbrueckii subsp bulgaricus, and B. bifidum
  • The 4-strain combination of L. acidophilus, L. delbrueckii subsp bulgaricus, B. bifidum, and S. salivarius subsp thermophilus

• Dosage is critical - higher doses (≥10 billion CFU/day) show better efficacy 1

Acute Infectious Diarrhea

• The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) recommends: 2

  • Saccharomyces boulardii CNCM I-745
  • Lactobacillus rhamnosus GG
  • Lactobacillus reuteri DSM 17938

• These probiotics can reduce diarrhea duration by approximately 21.91 hours and decrease the risk of prolonged diarrhea (>3 days) by 38% 1

Clostridium difficile-Associated Diarrhea

• Evidence suggests S. boulardii may increase cessation of diarrhea (RR, 1.33; 95% CI, 1.02-1.74) and decrease recurrence (RR, 0.59; 95% CI, 0.35-0.98) 2
• However, the AGA notes that current evidence is heterogeneous and of low quality 2

Strain-Specific Efficacy

Not all Lactobacillus strains are equally effective:

1. Most Effective Strains:

   • Lactobacillus rhamnosus GG - strong evidence for prevention of nosocomial diarrhea and treatment of acute gastroenteritis 2
   • Saccharomyces boulardii - effective for antibiotic-associated diarrhea and C. difficile infection 2, 3
   • Lactobacillus reuteri - effective for acute gastroenteritis, especially in breastfed infants with colic 2, 4

2. Less Effective or Uncertain:

   • Lactobacillus acidophilus - showed no significant benefit in some studies 5, 6
   • Lactobacillus rhamnosus ATCC 53103 - may actually increase recurrence of C. difficile infection 2

Dosage and Administration

• Effective dosage: ≥10 billion CFU/day 1, 3
• Timing: Should be taken 2 hours apart from antibiotics when used for antibiotic-associated diarrhea 1
• Duration: Continue throughout antibiotic course and for 1-2 weeks after completion 1
• Multi-strain probiotics often demonstrate better outcomes than single-strain options 1, 7

Safety Considerations

• Generally safe with low adverse event rates (4% in probiotic groups vs 6% in control groups) 1
• Use with caution in:
  • Premature neonates
  • Immunocompromised patients
  • Critically ill patients
  • Patients with central venous catheters
  • Patients with cardiac valvular disease
  • Patients with short-gut syndrome 2

Clinical Algorithm for Probiotic Selection

1. For antibiotic-associated diarrhea prevention:

   • First choice: S. boulardii or L. rhamnosus GG at ≥10 billion CFU/day
   • Alternative: Multi-strain combinations as recommended by AGA

2. For acute infectious diarrhea treatment:

   • First choice: L. rhamnosus GG or S. boulardii at ≥10 billion CFU/day
   • Alternative: L. reuteri (especially in breastfed infants)

3. For C. difficile infection:

   • Consider S. boulardii as adjunct to appropriate antibiotic therapy
   • Avoid L. rhamnosus ATCC 53103 due to potential increased recurrence

4. For high-risk patients (immunocompromised, critically ill):

   • Avoid probiotics due to safety concerns

Remember that rehydration remains the primary treatment for diarrhea, with probiotics serving as adjunctive therapy 1.