Probiotics as a Tx resource in primary care
While probiotics have not been marketed as drugs, clinicians can still recommend them in an evidence-based manner.
PRACTICE RECOMMENDATIONS
› Consider specific probiotics to prevent antibioticassociated diarrhea, reduce crying time in colicky infants, and improve therapeutic effectiveness of antibiotics for bacterial vaginosis. A
› Consider specific probiotics to reduce the risk for Clostridioides (formerly Clostridium) difficile infections, to treat acute pediatric diarrhea, and to manage symptoms of constipation. B
› Check a product’s label to ensure that it includes the probiotic’s genus, species, and strains; the dose delivered in colony-forming units through the end of shelf life; and expected benefits C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
What to look for in the future
Basic research, human trials, and market development in the field of probiotics are progressing rapidly. Probiotics at this time are primarily from the genera Lactobacillus, Bifidobacterium, and Saccharomyces. But the potential of probiotics has spurred research into previously untapped microbial members of the healthy human microbiota. Microbes such as Akkermansia, Faecalibacterium, and Rosburia may comprise “next-generation probiotics” that will likely be developed as drugs.72
Active areas of research holding some promise involve microbiome-driven components of intractable problems such as metabolic syndrome (obesity,73 diabetes, and lipid dysregulation) and brain dysfunction74 (depression, anxiety, cognition, autism). A guide to the clinical use of probiotic products available in the United States, updated yearly, may be a useful reference (but the reader may want to examine the referenced studies as their level of evidence is different than the SORT method).75 Science-based videos, infographics, and other resources are available from the International Scientific Association for Probiotics and Prebiotics, (mentioned earlier; www.isappscience.org/).
It appears that probiotics will continue to be widely used and hopefully in a more evidence-based manner. As we learn more about individual microbiome variations, recommendations will likely be more patient specific. Probiotics that have robust evidence represent the strongest recommendations. Even so, since the risks of using traditional probiotics (such as Lactobacillus, Bifidobacterium and Saccharomyces strains) are low, trial and error may be warranted at times.
CORRESPONDENCE
Daniel J. Merenstein, MD, 4000 Reservoir Road NW, Building D 240, Washington, DC 20007; djm23@georgetown.edu.
ACKNOWLEDGMENT
We thank Alexandra Mannerings, PhD, for preparing the FIGURE.
