What probiotics are recommended for prophylaxis during antibiotic therapy?

Recommended Probiotics for Prophylaxis During Antibiotic Therapy

For patients receiving antibiotics, specific probiotic strains should be used for prophylaxis, particularly Saccharomyces boulardii or a combination of Lactobacillus strains, to reduce the risk of antibiotic-associated diarrhea and Clostridioides difficile infection. 1

Recommended Probiotic Strains

• Saccharomyces boulardii I-745 at a dose of 1 g/day is recommended as a first-line probiotic for antibiotic prophylaxis based on multiple clinical trials showing efficacy 1
• A three-strain Lactobacilli combination (L. acidophilus CL1285, L. casei LBC80R, and L. rhamnosus CLR2) marketed as Bio-K+ has demonstrated significant reduction in C. difficile infection rates 1
• Two-strain combination of L. acidophilus CL1285 and L. casei LBC80R is conditionally recommended by the American Gastroenterological Association 1, 2
• Other effective options include L. casei Shirota and Lactobacillus plantarum 299v, which have shown efficacy in hospital studies 1
• A four-strain combination of L. acidophilus, L. delbrueckii subsp bulgaricus, B. bifidum, and Streptococcus salivarius subsp thermophilus is also recommended 1, 2

Dosing and Administration

• High-dose probiotics (≥5 billion CFUs per day) are more effective than low-dose probiotics (<5 billion CFUs per day) 3
• Probiotics should be started at the beginning of antibiotic therapy and continued throughout the course of antibiotics 2, 4
• Consider continuing probiotics for 1-2 weeks after completion of antibiotic therapy to support microbiota recovery 2, 4
• Administer probiotics at least 2 hours apart from antibiotics to maximize effectiveness 4

Patient Selection and Risk Stratification

• Probiotics are most beneficial for patients at high risk of C. difficile infection, including:
  • Elderly patients 1, 2
  • Hospitalized patients receiving antibiotics 1
  • Patients with previous episodes of antibiotic-associated diarrhea 1, 2
  • During C. difficile outbreaks in healthcare facilities 1
• For patients with a history of recurrent C. difficile infection, S. boulardii combined with high-dose vancomycin (2 g/day) has shown significant reduction in recurrence rates (17% vs 50%) 1

Important Contraindications and Precautions

• Probiotics are contraindicated in immunocompromised patients due to risk of bacteremia or fungemia 1
• Avoid probiotics in patients with central venous catheters due to risk of fungemia with S. boulardii 1, 5
• Use with caution in severely debilitated patients or those with compromised intestinal mucosal integrity 5, 3
• Potential minor adverse events include rash, nausea, gas, flatulence, abdominal bloating, and constipation, but these are generally rare 3, 6

Evidence Quality Considerations

• The overall quality of evidence supporting probiotic use for antibiotic prophylaxis is moderate 1, 2
• Meta-analyses show that probiotics reduce the risk of antibiotic-associated diarrhea by approximately 50% 5, 7
• The number needed to treat to prevent one case of antibiotic-associated diarrhea is approximately 9 patients overall, and 6 patients when using high-dose probiotics 1, 3
• Evidence suggests that probiotics may reduce the duration of diarrhea by almost one day when it does occur 3

By following these evidence-based recommendations for probiotic prophylaxis during antibiotic therapy, clinicians can significantly reduce the risk of antibiotic-associated diarrhea and C. difficile infection, particularly in high-risk patients.