Q: What are probiotics?

Q: My doctor has prescribed probiotics along with antibiotics? Is taking them together correct?

Krishna: Microbiota - the microscopic organisms of a particular environment - is very important for the  normal functioning of living bodies. 

The human body is inhabited by millions of tiny living organisms, which, all together, are called the human microbiota. Bacteria are microbes found on the skin, in the nose, mouth, and especially in the gut. We acquire these bacteria during birth and the first years of life, and they live with us throughout our lives.

The gut microbiome is a complex ecosystem of trillions of microbes that live together in harmony in our gastrointestinal tract. These microbes have far reaching effects on human health, enhancing digestion, immunity, skin health and energy. A balance is required between beneficial microbes and more harmful microbes that naturally colonise the gut. 

A principal function of the microbiota is to protect the intestine against colonization by exogenous pathogens and potentially harmful indigenous microorganisms via several mechanisms, which include direct competition for limited nutrients and the modulation of host immune responses.

The gut microbiota that resides in the gastrointestinal tract provides essential health benefits to its host, particularly by regulating immune homeostasis. Moreover, it has recently become obvious that alterations of these gut microbial communities can cause immune dysregulation, leading to autoimmune disorders.

If probiotics are your gut’s best friend, then Antibiotics are your gut’s worst enemy! Taking a probiotic alongside an antibiotic can help to minimise digestive upset that occurs as a result of the disruption to our gut microbiome, otherwise known as dysbiosis.

Replenishing the gut with probiotics helps to rebalance the gut microbiome following antibiotic use.  Based on a systematic review and meta-analysis of 23 randomized controlled trials including 4213 patients, evidence suggests that probiotics are both safe and effective in helping to support the health of the gut microbiome and reducing digestive upset. 

Patients taking antibiotics also take probiotics, which have been found to be effective both for the prevention and treatment of antibiotic-associated diarrhea (AAD). More than a third of patients taking antibiotics develop AAD, and in 17% of cases, AAD is fatal in children and the elderly. Antibiotics contribute to the development of diarrhoea, constipation and/or vaginal thrush . People taking antibiotics may also experience loss of appetite, bloating, nausea, indigestion, abdominal pain , fatigue, feeling low on energy or ‘wiped out’, and antibiotic-associated diarrhoea. 

Although diarrhea may be the result of increased gastrointestinal (GI) motility in some cases, a disruption of the GI flora that normally acts as a barrier to infection and aids in the digestion of carbohydrates is a far more common cause (1).

Antibiotics work by wiping out any and all bacteria, which makes them very effective for treating illnesses, but very bad for your microbiome. The antibiotic cannot recognize the difference between good gut bacteria and bad bacteria. They work on a ‘kill now ask questions later’ model. So you have to bring back your microbiota to normal level as soon as possible after taking antibiotics. Make sure to take prebiotics  for the duration of your prescription to help replenish your gut bacteria.

Probiotics replenish the natural GI flora with nonpathogenic organisms. Probiotics appear to be effective in preventing and treating AAD in children and adults receiving a wide variety of antibiotics for a number of conditions. So doctors sometimes prescribe  a supplement containing probiotics to minimise digestive upset that can often be associated with antibiotic use.

Prebiotics (not 'pro' I mentioned earlier, please keep in mind the difference) are food for your microbiome! It’s important to feed these bugs to give them the energy they need to complete their very important task of managing your  system properly. Here is a list of dietary prebiotics: whole grains, apples, onions, garlic, cocoa extracts, bananas, black grapes, asparagus, nuts, seeds, red wine extracts, root vegetables, beans, lentils, chickpeas and green tea extracts.

Probiotics have generally been considered safe; however, there have been rare reports of sepsis and fungemia associated with probiotic use, especially in immunosuppressed patients(2).

Now can you take probiotics with antibiotics?

Extensive clinical research suggests the best probiotic to take with antibiotics are particular strains that can be taken alongside antibiotics, rather than separately. These particular strains are Lactobacillus acidophilus Rosell-52, Lactobacillus rhamnosus Rosell-11 and Bifidobacterium lactis Lafti B94. These strains can be taken at exactly the same time as antibiotic medication, which is not the case for most other probiotic supplements. 

It's not necessarily bad or counterproductive to take other probiotic strains alongside antibiotic medication, it just means that the probiotic may not be viable, but rest assured, the antibiotic medication itself would not be affected. It’s always good to take strains of probiotics that have been studied to help with the health concern or situation you are looking to support as not all probiotics are the same.

Taking well-studied strains that have been shown to survive when taken at the same time as the antibiotic medication is particularly useful alongside intravenous (IV) antibiotics which may be constantly administered on a drip. It is a good idea to take probiotics during and after courses of antibiotics.

It’s important to select strains of probiotics that have been tested in clinical trials and have been shown to reach the gut alive when taken alongside antibiotics. The more friendly bacteria present in the gut, the lower the chance of developing digestive issues like diarrhoea. Three strains of probiotics in particular, Lactobacillus acidophilus Rosell-52, Lactobacillus rhamnosus Rosell-11 and  Bifidobacterium lactis Lafti B94 have been shown to do this. They can safely be taken at exactly the same time as antibiotic medication. 

In clinical trials involving those undergoing antibiotic treatment for Helicobacter pylori infection, participants were given Lactobacillus acidophilus Rosell-52, Lactobacillus rhamnosus Rosell-11 and Bifidobacterium lactis Lafti B94 alongside antibiotics; all three strains were proven to survive alongside the medication (3,4).

Don't antibiotics kill probiotics?

Only a few probiotic strains have been shown to survive when taken directly alongside antibiotics. As all antibiotic medication will have some kind of negative impact on the gut microbiome, it’s really important to choose the right strains of probiotics when taking this type of medication. You want strains that have not only been researched to survive when directly taken alongside antibiotics, but to also demonstrate that they exert benefits. 

The extensive research behind the three previously mentioned Lactobacillus strains set them apart from many probiotic supplements on the market today and make them a suitable choice for anyone who wishes to take natural bacteria during their course of antibiotics. Furthermore, Lactobacillus acidophilus Rosell-52, Lactobacillus rhamnosus Rosell-11 and Bifidobacterium lactis Lafti B94 have been tested and shown in-vitro to survive stomach acidity and bile salts.

Generally, with a few exceptions , it is best to take your probiotic supplements in the morning with breakfast. If you are taking a probiotic containing the strains Lactobacillus acidophilus Rosell-52, Lactobacillus rhamnosus Rosell-11 and Bifidobacterium lactis Lafti B94, you would still be able to follow this recommendation alongside antibiotics and take both with your breakfast.

However, if you are taking different strains, it is best to give a 2 hour gap between antibiotics and taking the probiotic supplement. So, if you have been instructed by your doctor to take your antibiotics with breakfast, you would take the medication first in this instance and leave a 2 hour gap before taking the other probiotics. It’s a good idea to take your supplements with food, so in this case, with your lunch or a mid-morning snack.

Ideally, any alternative probiotic strains taken should also have research demonstrating their efficacy during antibiotic therapy. If you are taking a probiotic from a different supplier, it is best to ask that supplier directly about the length of time to leave between taking their product and taking your antibiotics. As a general rule, many companies tend to recommend waiting 1 or 2 hours after taking antibiotics before taking their probiotics. After this length of time, sufficient levels of the beneficial bacteria are able to reach the gut alive.

It is generally recommended to take probiotics every day during your course of antibiotics; this way you can replenish your friendly bacteria daily before your digestive system is upset by a longstanding microbial imbalance.

We  are not really sure exactly how long it will take to rebuild the gut flora after antibiotics; it will depend on several different factors such as the individual gut microbiome, the length of the course, the strength of medication, diet and lifestyle etc. So, what are the best probiotics after antibiotics? Well, studies show taking a probiotic supplement that contains the strains Lactobacillus acidophilus NCFM and Bifidobacterium lactis Bi-07^® after antibiotics may help to stabilise Lactobacillus populations in the gut (6). The Lactobacillus genus of friendly bacteria helps to crowd out the bad ones and keep our gut environment healthy. 

It’s a good idea to look for research on the best probiotics when taking antibiotics long term if you are on longer courses of medication. If you need to take long term antibiotics, you may wish to consider choosing a supplement that contains Lactobacillus acidophilus NCFM^®. A supplement that contains this particular strain has been demonstrated in a randomised controlled trial to minimise disturbance to the composition of the gut microbiome when taken alongside antibiotics (5). This can be useful when antibiotics are being taken for longer than two weeks. 

Do probiotics affect antibiotics?

There is no suggestion in  research that probiotics interfere with the action of antibiotics in any way. In fact, doctors and GPs are often now recommending probiotic supplements and prebiotic and probiotic foods, such as yoghurts or kefir, to be taken alongside a course of antibiotics.

Footnotes:

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3601687/

2. Hempel S, Newberry S, Maher A, et al. probiotics for the prevention and treatment of antibiotic-associated diarrhea. JAMA. 2012;307:1959–1969. [PubMed] [Google Scholar]

3. Bowe WP, Logan AC. Acne vulgaris, probiotics and the gut-brain-skin axis - Back to the future? Gut Pathog. 2011;3(1):1. doi:10.1186/1757-4749-3-1

4. Zhang YJ, Li S, Gan RY, Zhou T, Xu DP, Li H Bin. Impacts of gut bacteria on human health and diseases. Int J Mol Sci. 2015;16(4):7493-7519. doi:10.3390/ijms16047493

5. Kamada N, Seo SU, Chen GY, Núñez G. Role of the gut microbiota in immunity and inflammatory disease. Nat Rev Immunol. 2013;13(5):321-335. doi:10.1038/nri3430

6. Forssten, S., et al., (2014). ‘Influence of a probiotic mixture on antibiotic induced microbiota disturbances’. World Journal of Gastroenterology, 20(33):11878-85.