Probiotics with Augmentin: Evidence-Based Recommendations
Yes, specific probiotic strains can help prevent antibiotic-associated diarrhea and Clostridioides difficile infection when taking Augmentin (amoxicillin/clavulanate), with Saccharomyces boulardii and specific Lactobacillus combinations showing the strongest evidence. 1, 2
Recommended Probiotic Strains
The American Gastroenterological Association (AGA) conditionally recommends the following specific probiotics when taking antibiotics like Augmentin:
First-Line Options:
- Saccharomyces boulardii (1g or 3×10¹⁰ CFU/day) - reduces C. difficile-associated diarrhea risk by 59% and is the most extensively studied single-strain probiotic 1, 3
- This yeast-based probiotic has a unique advantage: antibiotics don't kill yeast, so it survives concurrent antibiotic therapy better than bacterial probiotics 4
- Importantly, S. boulardii does not alter the pharmacokinetics or efficacy of amoxicillin (the main component of Augmentin) 5
Multi-Strain Alternatives:
- Two-strain combination: Lactobacillus acidophilus CL1285 + Lactobacillus casei LBC80R - reduces risk by 78% 1, 2
- Three-strain combination: L. acidophilus + L. delbrueckii subsp bulgaricus + Bifidobacterium bifidum - reduces risk by 65% 1
- Four-strain combination: L. acidophilus + L. delbrueckii subsp bulgaricus + B. bifidum + Streptococcus salivarius subsp thermophilus - reduces risk by 72% 1
How to Use Probiotics with Augmentin
Timing and Duration:
- Start probiotics at the beginning of Augmentin therapy 2
- Take probiotics at least 2 hours apart from Augmentin doses to avoid direct antimicrobial effects on bacterial probiotics 2
- Continue throughout the entire course of antibiotic treatment 1, 2
- Consider continuing for 1-2 weeks after completing Augmentin 2
Expected Benefits:
- Reduces antibiotic-associated diarrhea risk by up to 64% 2, 6
- Decreases C. difficile infection risk by approximately 60% in high-risk patients 1
- Shortens duration of diarrhea by approximately 1 day if it does occur 7
Critical Contraindications
Do not use probiotics if you are immunocompromised - this includes patients with HIV/AIDS, active chemotherapy, organ transplant recipients, or those on immunosuppressive medications, due to risk of bacteremia or fungemia 1, 2
Who Benefits Most
High-risk patients who should strongly consider probiotics with Augmentin include:
- Elderly patients (>65 years) 1
- Those with prolonged hospitalization 1
- Patients with previous C. difficile infection 1
- Individuals with severe underlying illness 1
Evidence Quality Considerations
The overall quality of evidence is rated as low to moderate by the AGA, primarily due to heterogeneity in study populations, probiotic strains tested, and outcome measures 4, 1. However, the consistent signal of benefit across multiple meta-analyses (including a Cochrane review of 63 RCTs with 11,811 participants showing a 42% reduction in antibiotic-associated diarrhea) supports their use 6. The effect is highly strain-specific - not all probiotics are equally effective, which is why choosing one of the specifically studied strains listed above is essential 4, 3.
Common Pitfalls to Avoid
- Don't use generic "probiotic" supplements - efficacy is strain-specific, so choose products containing the exact strains listed above 3
- Don't take probiotics at the same time as Augmentin - separate by at least 2 hours 2
- Don't assume all Lactobacillus or Bifidobacterium strains work equally - only specific strain combinations have proven efficacy 4, 1
- Don't use in immunocompromised patients - the risks outweigh benefits in this population 1, 2