Best Probiotic for Augmentin-Associated Diarrhea
For patients experiencing diarrhea from Augmentin (amoxicillin/clavulanate), use Saccharomyces boulardii at 1g daily (3×10¹⁰ CFU/day) or Lactobacillus rhamnosus GG at 5-10 billion CFU/day, started immediately and continued throughout the antibiotic course. 1, 2
Primary Recommendation: Saccharomyces boulardii
Saccharomyces boulardii is the single most effective probiotic for antibiotic-associated diarrhea, with the strongest evidence base among single-strain probiotics. 1
Why S. boulardii is Superior:
- Reduces antibiotic-associated diarrhea duration by approximately 28.9 hours (95% CI: 16.78-41.03 hours) 3
- Decreases C. difficile-associated diarrhea recurrence by 59% (RR 0.59; 95% CI 0.35-0.98) 1, 2
- Uniquely resistant to antibiotics because it is a yeast (eukaryote), not a bacterium—meaning Augmentin cannot kill it, making it ideal for concurrent administration 4
- Dose: 1g daily or 3×10¹⁰ CFU/day 1, 2
Alternative Option: Lactobacillus rhamnosus GG
Lactobacillus rhamnosus GG is the second-best choice with robust evidence for antibiotic-associated diarrhea prevention. 1, 2
Evidence for L. rhamnosus GG:
- Reduces diarrhea duration by approximately 23.13 hours (95% CI: 12.33-33.94 hours) 3
- Effective at 5-10 billion CFU/day with low probability of adverse events 2
- Well-studied in both children and adults for antibiotic-associated diarrhea 5, 6
Multi-Strain Alternatives (If Single Strains Unavailable)
If neither S. boulardii nor L. rhamnosus GG is available, consider these evidence-based combinations:
Two-Strain Combination:
- Lactobacillus acidophilus CL1285 + Lactobacillus casei LBC80R reduces C. difficile risk by 78% (RR 0.22; 95% CI 0.11-0.42) 1, 2
Three-Strain Combination:
- L. acidophilus + L. delbrueckii subsp bulgaricus + Bifidobacterium bifidum reduces C. difficile risk by 65% 7, 3
Four-Strain Combination:
- L. acidophilus + L. delbrueckii subsp bulgaricus + B. bifidum + Streptococcus salivarius subsp thermophilus reduces C. difficile risk by 72% 7, 3
Timing and Duration Protocol
Start probiotics immediately when beginning Augmentin or within 48 hours of antibiotic initiation to maximize effectiveness. 4
- Continue throughout the entire antibiotic course 7, 3
- Consider extending 1-2 weeks after completing antibiotics for high-risk patients 7
- Do not exceed 12 weeks of continuous use without reassessment 3
Critical Safety Contraindications
Absolutely avoid probiotics in immunocompromised patients due to risk of bacteremia or fungemia. 7, 3, 2
High-Risk Populations (Contraindicated):
- Neutropenic patients 2
- HIV/AIDS patients 2
- Active chemotherapy recipients 2
- Patients with central venous catheters 3, 2
- Severely debilitated or critically ill patients 2
- Cardiac valvular disease 3
- Short-gut syndrome 3
Evidence Quality and Practical Considerations
The overall quality of evidence is rated as LOW to MODERATE due to heterogeneity in study populations and probiotic strains. 1, 2
Important Caveats:
- Efficacy is strain-specific—not all probiotics labeled as "Lactobacillus" or "probiotic" are equally effective 7, 5
- Dose matters: Higher doses (≥10¹⁰ CFU/day) are generally more effective 3, 2
- Product quality varies: Many supplements do not contain declared strains or doses; contamination with pathogens is documented 2
- Verify bacterial viability until end of shelf life on product label 2
Clinical Decision Algorithm:
For immunocompetent patients with Augmentin-associated diarrhea:
- First choice: Saccharomyces boulardii 1g daily 1, 2
- Second choice: Lactobacillus rhamnosus GG 5-10 billion CFU/day 2
- Third choice: Multi-strain combinations (2-, 3-, or 4-strain formulations) 1, 7
For high-risk patients (elderly, prolonged hospitalization, previous C. difficile infection):
- Strongly consider prophylactic probiotics at antibiotic initiation 7
- Prefer S. boulardii or multi-strain combinations for enhanced protection 1, 7
For immunocompromised patients: