Abstract
Infectious gastroenteritis continues to be a leading cause of mortality and morbidity worldwide. The cornerstone of treatment remains replacement of water and electrolyte losses with oral rehydration solution. Until a few years ago, probiotics were discussed primarily in the context of alternative medicine, but they are now entering mainstream medical practice since a decrease of the severity and duration of infectious gastroenteritis in approximately 24 hours has been shown for some strains. Therefore, probiotics are a potential add-on therapy in acute gastro-enteritis. The shortening of the duration of diarrhoea and the reduction in hospital stay result in a social and economic benefit. Evidence found in viral gastroenteritis is more convincing than in bacterial or parasitic infection. Mechanisms of action are strain specific and only those commercial products for which there is evidence of clinical efficacy should be recommended. Timing of administration is also of importance. In acute gastroenteritis, there is evidence for efficacy of some strains of lactobacilli (e.g. Lactobacillus caseii GG and Lactobacillus reuteri) and for Saccharomyces boulardii. Probiotics are “generally regarded as safe”, but side effects such as septicaemia and fungaemia have very rarely been reported in high-risk situations. Although most studies conclude in a statistically significant shortening of the duration of diarrhea, the clinical relevance of this finding is limited. In conclusion, selected strains of probiotics result in a statistically significant but clinically moderate benefit in shortening the duration of diarrhoea caused by acute infectious gastroenteritis.
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Agostoni C, Axelsson I, Braegger C, Goulet O, Koletzko B, Michaelsen KF, Rigo J, Shamir R, Szajewska H, Turck D, Weaver LT, ESPGHAN Committee on Nutrition (2004) Probiotic bacteria in dietetic products for infants: A commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 38:365–374
Alam S, Bhatnagar S (2006) Current status of anti-diarrheal and anti-secretory drugs in the management of acute childhood diarrhea. Indian J Pediatr 73:693–696
Allen SJ, Okoko B, Martinez E, Gregorio G, Dans LF (2004) Probiotics for treating infectious diarrhea. Cochrane Database Syst Rev 2:CD003048
Bernet MF, Brassart D, Neeser JR, Servin AL (1994) Lactobacillus acidophilus LA 1 binds to cultured human intestinal cell lines and inhibits cell attachment and cell invasion by enterovirulent bacteria. Gut 35:483–488
Billoo AG, Memon MA, Khaskheli SA, Murtaza G, Iqbal K, Saeed Shekhani M, Siddiqi A (2006) Role of a probiotics (Saccharomyces boulardii) in the management and prevention of diarrhea. World J Gastroenterol 12:4557–4560
Borriello SP, Hammes WP, Holzapfel W, Marteau P, Schrezenmeir J, Vaara M, Valtonen V (2003) Safety of probiotics that contain Lactobacilli or Bifidobacteria. Clin Infect Dis 36:775–780
Bruzesse E (2006) Early administration of GOS/FOS prevents intestinal and respiratory infections in infants. J Pediatr Gastroenterol Nutr 42:E1–E110
Buts JP, De Keyser N (2006) Effects of Saccharomyces boulardii on intestinal mucosa. Dig Dis Sci 51:1485–1492
Cabana MD, Shane AL, Chao C, Oliva-Henker M (2006) Probiotics in primary care pediatrics. Clin Pediatr 45:405–410
Casburn-Jones AC, Farthing MJ (2004) Management of infectious diarrhoea. Gut 53:296–305
Cassone M, Serra P, Mondello F, Girolamo A, Scafetti S, Pistella E, Venstaditti M (2003) Outbreak of S. cerevisiae subtype boulardii fungemia in patients neighboring those treated with a probiotic preparation of the organism. Clin Microbiol 41:5340–5343
Castañeda C, Garcia E, Santa Cruz M, Fernandez M, Monterrey P (1995) Effects of Saccharomyces boulardii in children with chronic diarrhea, especially cases due to giardiasis. Revista Mexicana de Puericultura y Pediatria 2:12–16
Cetina-Sauri G, Sierra Basto G (1994) Therapeutic evaluation of Saccharomyces boulardii in children with acute diarrhea. Ann Pediatr 41:397–400
Chouraqui JP, Van Egroo LD, Fichot MC (2004) Acidified milk formula supplemented with Bifidobacterium lactis: impact on infant diarrhea in residual care settings. J Pediatr Gatsroenterol Nutr 38:288–292
Coconnier MH, Lievin V, Bernet-Camard MF, Hudault S, Servin AL (1997) Antibacterial effect of the adhering human Lactobacillus acidophilus strain LB. Antimicrob Agents Chemother 41:1046–1052
Costa-Ribeiro H, Ribeiro TC, Mattos AP, Valois SS, Neri DA, Almeida P, Cerqueira CM, Ramos E, Young RJ, Vanderhoof JA (2003) Limitations of probiotic therapy in acute, severe dehydrating diarrhea. J Pediatr Gastroenterol Nutr 36:112–115
De Preter V, Vanhoutte T, Huys G, Swings J, Rutgeerts P, Verbeke K (2006) Effect of lactulose and Saccharomyces boulardii administration on the colonic urea-nitrogen metabolism and the bifidobacteria concentration in healthy human subjects. Aliment Pharmacol Ther 23:963–974
De Preter V, Vanhoutte T, Huys G, Swings J, De Vuyst L, Rutgeerts P, Verbeke K (2006) Effects of Lactobacillus casei Shirota, Bifidobacterium breve, and oligofructose-enriched inulin on the colonic nitrogen-protein metabolism in healthy humans. Am J Physiol Gastrointest Liver Physiol 292:G358–G368
Duggan C, Gannon J, Waker WA (2002) Protective nutrients and functional foods for the gastrointestinal tract. Am J Clin Nutr 75:789–808
Elliott E, Teversham K (2004) An evaluation of nine probiotics available in South Africa, August 2003. SAMJ 94:121–124
Enache-Angoulvant A (2005) Invasive Saccharomyces infection: a comprehensive review. Clin Infect Dis 41:1559–1568
Fedorak RN, Madsen KI (2004) Probiotics and prebiotics in gastrointestinal disorders. Curr Opin Gastroenterol 20:146–155
Guandalini S, Pensabene L, Zikri MA, Dias JA, Casali LG, Hoekstra H, Kolacek S, Massar K, Micetic-Turk D, Papadopoulou A, de Sousa JS, Sandhu B, Szajewska H, Weizman Z (2000) Lactobacillus GG administered in oral rehydration solution in children with acute diarrhea: a multicenter European trial. J Pediatr Gastroenterol Nutr 30:214–216
Guarino A, Berni Canani R, Spagnuolo MI, Bisceglia M, Boccia MC, Rubino A (1997) Oral bacterial therapy reduces the duration of symptoms and viral excretion in children with mild diarrhea. J Pediatr Gastroenterol Nutr 25:516–519
Hilton E, Kolakowski P, Singer C, Smith M (1997) Efficacy of Lactobacillus GG as a diarrheal preventive in travelers. J Travel Med 4:41–43
Höchter W, Chase D, Hagenhoff G (1990) Saccharomyces boulardii bei akuter Erwachsenendiarrhoe. Münch Med Wschr 132:188–192
Huang JS, Bousvaros A, Lee JW, Diaz A, Davidson EJ (2002) Efficacy of probiotic use in acute diarrhea in children: a meta-analysis. Dig Dis Sci 47:2625–2634
Ibnou-Zekri N, Blum S, Schiffrin EJ, von der Weid T (2003) Divergent patterns of colonization and immune response elicited from two intestinal Lactobacillus strains that display similar properties in vitro. Infect Immun 71:428–436
Isolauri E, Juntunen M, Rautanen T, Sillanaukee P, Koivula T (1991) A human Lactobacillus strain (Lactobacillus casei sp strain GG) promotes recovery from acute diarrhea in children. Pediatrics 88:90–97
Jijon H, Backer J, Diaz H, Yeung H, Thiel D, McKaigney C, De Simone C, Madsen K (2004) DNA from probiotic bacteria modulates murine and human epithelial and immune function. Gastroenterology 126:1358–1373
Juntunen M, Kirjavainen PV, Ouwehand AC, Salminen SJ, Isolauri E (2001) Adherence of probiotic bacteria to human intestinal mucus in healthy infants and during rotavirus infection. Clin Diagn Lab Immunol 8:293–296
Katelaris PH, Salam I, Farthing MJ (1995) Unspecified Lactobacillus acidophilus in prevention traveler’s diarrhea. N Eng J Med 333:1360–1361
Khanna V, Alam S, Malik A (2005) Efficacy of tyndalized Lactobacillus acidophilus in acute diarrhea. Indian J Pediatr 72:935–938
Kollaritsch H (1989) Traveller’s diarrhea among Austrian tourists to warm climate countries: II. Clinical features. Eur J Epidemiol 5:355–362
Kowalska-Duplaga K, Fyderek K, Szajewska H, Janiak R (2004) Efficacy of Trilac® in the treatment of acute diarrhoea in infants and young children - a multicentre, randomized, double-blind placebo-controlled study. Pediatria Współczesna 3:295–299
Kurugol Z, Koturoglu G (2005) Effects of Saccharomyces boulardii in children with acute diarrhoea. Acta Paediatr 94:44–47
Land MH, Rouster-Steven K, Woods Dr (2005) Lactobacillus sepsis associated with probiotic therapy. Pediatrics 115:178–181
Lilly DM, Stillwell RH (1965) Probiotic growth promoting factors produced by microorganisms. Science 147:747–748
Mackay AD, Taylor MB, Kibbler CC, Hamilton-Miller JM (1999) Lactobacillus endocarditis caused by a probiotics organism. Clin Microbiol Infect 5:290–292
Mansour-Ghanaei F, Dehbashi N, Yazdanparast K, Shafaghi A (2003) Efficacy of Saccharomyces boulardii with antibiotics in acute amoebiasis. World J Gastroenterol 9:1832–1833
Marteau P, Pochart P, Bouhnik Y, Zidi S, Goderel I, Rambaud JC (1992) Survival of Lactobacillus acidophilus and Bifidobacterium sp. in the small intestine following ingestion in fermented milk. A rational basis for the use of probiotics in man. Gastroenterol Clin Biol 16:25–28
Mastretta E, Longo P, Laccisaglia A, Balbo L, Russo R, Mazzaccara A, Gianino P (2002) Effect of a Lactobacillus GG and breast-feeding in the prevention of rotavirus nosocomial infection. J Pediatr Gastroenterol Nutr 35:527–531
Michail S, Abernathy F (2002) Lactobacillus plantarum reduces the in vitro secretory response of intestinal epithelial cells in enteropathogenic Escherichia coli infection. J Pediatr Gastroenterol Nutr 35:350–355
NASPGHAN Nutrition Report Committee; Michail S, Sylvester F, Fuchs G, Issenman R (2006) Clinical efficacy of probiotics: review of the evidence with focus on children. J Pediatr Gastroenterol Nutr 43:550–557
Oksanen PJ, Salminen S, Saxelin M, Hamalainen P, Ihantola-Vormisto A, Muurasniemi-Isoviita L, Nikkari S, Oksanen T, Porsti I, Salminen E, et al (1990) Prevention of travellers’ diarrhoea by Lactobacillus GG. Ann Med 22:53–56
Rautio M, Jousimies-Somer H, Kauma H, Pietarinen I, Saxelin M, Tynkkynen S, Koskela M (1999) Liver abcess due to a Lactobacillus rhamnosus strain indistinguishable from a L. rhamnosus strain GG. Clin Infect Dis 28:1159–1160
Raza S, Graham SM, Allen SJ (1995) Lactobacillus GG promotes recovery from acute nonbloody diarrhea in Pakistan. Pediatr Infect Dis J 14:107–111
Saavedra JM, Bauman NA, Oung I, Perman JA, Yolken RH (1994) Feeding of Bifidobacterium bifidum and Streptococcus thermophilus to infants in hospital for prevention of diarrhoea and shedding of rotavirus. Lancet 344:1046–1049
Saint-Marc T, Rossello-Prats L, Touraine JL (1991) Efficacy of Saccharomyces boulardii in the treatment of diarrhea in AIDS. Ann Med Interne (Paris) 142:64–65
Salazar-Lindo E, Miranda-Langschwager P, Campos-Sanchez M, Chea-Woo E, Sack RB (2004) Lactobacillus casei strain GG in the treatment of infants with acute watery diarrhea: A randomized, double-blind, placebo controlled clinical trial [ISRCTN67363048]. BMC Pediatr 4:18
Saran S, Gopalan S, Krishna TP (2002) Use of fermented foods to combat stunting and failure to thrive. Nutrition 18:393–396
Sarker SA, Sultana S, Fuchs GJ, Alam NH, Azim T, Brussow H, Hammarstrom L (2005) Lactobacillus paracasei strain ST11 has no effect on rotavirus but ameliorates the outcome of nonrotavirus diarrhea in children from Bangladesh. Pediatrics 116:e221–e228
Sazawal S, Hiremath G, Dhingra U, Malik P, Deb S, Black RE (2006) Efficacy of probiotics in prevention of acute diarrhoea: a meta-analysis of masked, randomised, placebo-controlled trials. Lancet Infect Dis 6:374–382
Shamir R, Makhoul IR, Etzioni A, Shehadeh N (2005) Evaluation of a diet containing probiotics and zinc for the treatment of mild diarrheal illness in children younger than one year of age. J Am Coll Nutr 24:370–375
Shornikova AV, Isolauri E, Burkanova L, Lukovnikova S, Vesikari T (1997) A trial in the Karelian Republic of oral rehydration and Lactobacillus GG for treatment of acute diarrhoea. Acta Paediatr 86:460–465
Shornikova AV, Casas IA, Mykkanen H, Salo E, Vesikari T (1997) Bacteriotherapy with Lactobacillus reuteri in rotavirus gastroenteritis. Pediatr Infect Dis J 16:1103–1107
Simakachorn N, Pichaipat V, Rithipornpaisarn P, Kongkaew C, Tongpradit P, Varavithya W (2000) Clinical evaluation of the addition of lyophilized, heat-killed Lactobacillus acidophilus LB to oral rehydration therapy in the treatment of acute diarrhea in children. J Pediatr Gastroenterol Nutr 30:68–72
Sougioultzis S, Simeonidis S, Bhaskar KR, Chen X, Anton PM, Keates S, Pothoulakis C, Kelly CP (2006) Saccharomyces boulardii produces a soluble anti-inflammatory factor that inhibits NF-kappaB-mediated IL-8 gene expression. Biochem Biophys Res Commun 343:69–76
Szajewska H, Kotowska M, Mrukowicz JZ, Armanska M, Mikolajczyk W (2001) Efficacy of Lactobacillus GG in prevention of nosocomial diarrhea in infants. J Pediatr 138:361–365
Szajewska H, Mrukowicz JZ (2005) Use of probiotics in children with acute diarrhea. Paediatr Drugs 7:111–122
Szajewska H, Setty M, Mrukowicz J, Guandalini S (2006) Probiotics in gastrointestinal disease in children: hard and not-so-hard evidence of efficacy. J Pediatr Gastroenterol Nutr 42:454–475
Szajewska H, Mrukowicz JZ (2001) Probiotics in the treatment and prevention of acute infectious diarrhea in infants and children: a systematic review of published randomized, double-blind, placebo-controlled trials. J Pediatr Gastroenterol Nutr 33:S17–S25
Szajewska H, Skorka A, Dylag M (2007) Meta-analysis: Saccharomyces boulardii for treating acute diarrhoea in children. Aliment Pharmacol Ther 25;257–64
Szymanski H, Pejcz J, Jawien M, Chmielarczyk A, Strus M, Heczko PB (2006) Treatment of acute infectious diarrhoea in infants and children with a mixture of three Lactobacillus rhamnosus strains-a randomized, double-blind, placebo-controlled trial. Aliment Pharmacol Ther 23:247–253
Szymanski H, Chmielarczyk A, Strus M, Pejcz J, Jawien M, Kochan P, Heczko PB (2006) Colonisation of the gastrointestinal tract by probiotic L. rhamnosus strains in acute diarrhoea in children. Dig Liver Dis 38(Suppl 2):S274–S276
Temmerman R, Pot B, Huys G, Swings J (2003) Identification and antibiotic susceptibility of bacterial isolates from probiotic products. Int J Food Microbiol 81:1–10
Thibault H, Aubert-Jacquin C, Goulet O (2004) Effects of long-term consumption of a fermented infant formula (with Bifidoacterium breve c50 and Streptococcus thermophilus 065) on acute diarrheda in healthy infants. J Pediatr Gastroenterol Nutr 39:147–152
Tissier H (1906) Traitement des infections intestinales par la méthode de la transformation de la flore bactérienne de l’intestin. C R Soc Biol 60:359–361
Van Niel CW, Feudtner C, Garrison MM, Christakis DA (2002) Lactobacillus therapy for acute infectious diarrhea in children: a meta-analysis. Pediatrics 109:678–84
Villarruel G, Rubio DM, Lopez F, Cintioni J, Gurevech R, Romero G, Vandenplas Y (2007) Saccharomyces boulardii in acute childhood diarrhea: a randomized, placebo-controlled study. Acta Paediatr (in press)
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An erratum to this article can be found at http://dx.doi.org/10.1007/s00431-007-0585-x
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Vandenplas, Y., Salvatore, S., Viera, M. et al. Probiotics in infectious diarrhoea in children: are they indicated?. Eur J Pediatr 166, 1211–1218 (2007). https://doi.org/10.1007/s00431-007-0497-9
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DOI: https://doi.org/10.1007/s00431-007-0497-9