Can You Take Saccharomyces boulardii (Florastor) While on Dexlansoprazole 60 mg to Prevent C. difficile?
Yes, you can take Saccharomyces boulardii while on dexlansoprazole 60 mg, but the evidence for its effectiveness in preventing primary C. difficile infection is weak, and current guidelines recommend probiotics only in clinical trials for CDI prevention. 1
Guideline Recommendations on Probiotics for CDI Prevention
The 2018 IDSA/SHEA guidelines state there are insufficient data to recommend probiotics for primary prevention of CDI outside of clinical trials (no recommendation). 1
The 2020 AGA guidelines offer a conditional recommendation (low-quality evidence) suggesting that in adults and children on antibiotic treatment, you may use specific probiotic strains including S. boulardii to prevent C. difficile infection. 1
The AGA specifically notes that patients who place high value on potential harms (particularly those with severe illnesses) or high value on avoiding cost and a low value on the small risk of CDI development would reasonably select no probiotics. 1
Safety Considerations with Dexlansoprazole
The IDSA/SHEA guidelines acknowledge an epidemiologic association between proton pump inhibitor (PPI) use and CDI, but state there is insufficient evidence for discontinuing PPIs as a CDI prevention measure. 1
There is no pharmacologic interaction between dexlansoprazole and S. boulardii that would preclude concurrent use. 1
Critical Safety Warnings for S. boulardii
S. boulardii has caused fungemia in critically ill patients, particularly those who are mechanically ventilated, have central venous catheters, or are severely immunocompromised. 2
Do not use S. boulardii if you are critically ill, immunocompromised, have a central venous catheter, or are hospitalized in an intensive care setting, as cases of bloodstream infection with this yeast have been documented. 2
The risk appears highest when packets are opened near central lines or in patients with disrupted intestinal barriers. 2
Evidence Quality and Clinical Context
For primary prevention (preventing a first episode of CDI in someone taking antibiotics), the evidence for S. boulardii is weak and underpowered, with studies lacking statistical significance. 3
For secondary prevention (preventing recurrence in someone who already had CDI), there is better evidence: one trial showed S. boulardii combined with high-dose vancomycin reduced recurrence from 50% to 16.7% (P=0.05). 4
The AGA's conditional recommendation reflects this limited evidence base and acknowledges that different patients will make different choices based on their values regarding cost, potential benefit, and theoretical risks. 1
Practical Algorithm for Decision-Making
Proceed with S. boulardii if ALL of the following are true:
- You are NOT critically ill, immunocompromised, or hospitalized in intensive care 2
- You do NOT have a central venous catheter 2
- You are currently taking antibiotics that increase CDI risk (fluoroquinolones, clindamycin, cephalosporins) 1
- You accept the cost and uncertain benefit for a small absolute risk reduction 1
Do NOT use S. boulardii if ANY of the following apply:
- You are critically ill or in an ICU setting 2
- You are severely immunocompromised 2
- You have a central venous catheter 2
- You prefer to avoid unproven interventions when guidelines offer no firm recommendation 1
Bottom Line
The combination of dexlansoprazole 60 mg and S. boulardii is not contraindicated, but the probiotic's benefit for primary CDI prevention remains unproven. 1 If you are otherwise healthy and taking high-risk antibiotics, the AGA suggests S. boulardii is a reasonable option, though the IDSA considers the evidence insufficient to recommend it outside research settings. 1 The most important CDI prevention strategy remains minimizing unnecessary antibiotic exposure and duration. 1