Probiotics in case of long term antibiotic therapy

Question

Hello,
my daughter (6-years-old, CF) gets for some years a long term antibiotic treatment. She had often diarrhea and abdominal pain, now she gets for nearly one year LGG capsules and the problems have been gotten better a lot. The health insurance, however, does not want to cover the costs for the past and the future, as the preparations are dietary supplements. She is not taking the capsules for one week now anymore and she starts again having diarrhea and stomach ache; can I assume, that the capsules did indeed help that much? Or do you think she has rather an infection? Is there any data, that I could present the health insurance, that proof the effectiveness of the probiotics? How can I convince the health insurance from covering the costs?
Many thanks,
Best regards,
V.M.

Answer

Dear questioner,
probiotics are viable microorganisms, that are taken orally, settle in the bowel and should improve the health of the bowel by many different ways:
prevention of a mis-colonization of the bowel with pathogenic bacteria and therefore positive influence of the bowel flora, formation of a barrier against the adherence of pathogenic bowel germs, stimulation of the gut-associated immune system.
When taking antibiotics not only the pathogenetic germs are killed, however also the beneficial germs of the bowel, therefore it comes frequently to symptoms of the gastro-intestinal tract. The cause is in most cases an impairment of the colonization of the bowel, as a consequence carbohydrates are less well digested, therefore stay in the bowel and impair the resorption of water from the inside of the bowel. The consequence is osmotic diarrhea. One speaks about an antibiotic-associated diarrhea. A special form and the maximum form is the so-called clostridium difficilie diarrhea (also called pseudo-membraneous enterocolitis), that can be observed after the intake of antibiotics, as this pathogenetic germ can multiply strongly due to a selection because of the antibiotic treatment.

If one takes a look at the concrete data on the question: "Does the intake of probiotics prevent the occurrence of antibiotic-associated diarrhea", there are on the one hand many studies, that addressed this question, however as there are many different probiotics (e.g. Lactobacillus GG, Lactobacillus acidophilus, Saccharomyces cerevisiae, Bifidobacterium etc.), the results of single studies with a certain preparation can not be transferred to another preparation. One would have to do, strictly speaking, seperate studies for each preparation, in order to be able to compare the results of the studies.

Another problem is the still unsolved (because not yet been investigated) question, what is the right timepoint for taking the probiotics. In case of a short-term antibiotic therapy it is not clear, if one should rather take the probiotics before or at least at the same time when beginning the antibiotics, or rather after finishing the antibiotic therapy, because theoretically, the antibiotics could also destroy the probiotic germs. In the case of your daughter, the questions does however not rise, as she is receiving a long term antibiotic therapy.
Now to the data. Unfortunatley, all data that I will list here, is in English, as one gets such data via a search in the databank "Pubmed". To list single studies, does not make sense here, but some authors tried to bring all single studies on the topic together and to judged it in a so-called metaanalysis. Some of these metaanalysis I would like to state here (concrete sources see at the end of the answer).
2010 there was a metaanalysis investigating the role of Lactobacillus on the prevention of antibiotic-associated diarrhea (1).
Here, 10 studies have been investigated, that used preparations with one stem of Lactobacillus (how many used indeed Lactobacillus GG, it became not clear). It could have been shown, that the intake of Lactobacillus during an antibiotic therapy reduced the risk of an antibiotic associated diarrhea in comparison to placebo, however only in adults, not in children.
2011 16 studies have been investigated in a cochrane database analysis (2). In those studies, different preparations have been used (Bacillus, Bifidobacterium, Lactobacillus etc.) and in spite of the different preparations, dosages and duration of intake, the analysis could show a protective effect of probiotics in the prevention of antibiotic-associated diarrhea.
2012 a metaanalysis of 81 studies concluded, that the data suggests that probiotics lead to a reduction of the occurrence of antibiotic-associated diarrhea (3).
2013 there was again a metaanalysis, that included 16 studies and that could show for preparations based on Lactobacillus that the intake reduced the risk of antibitotic-associated diarrhea (4).
On the other side, there has been a multicenter study in 2013, that fullfilled the demanded quality criteria (double-blind, placebo controlled, randomized) and that has been published in the prestigious Journal "Lancet" (5). This study used a preparation with different stems of Lactobacillus and bifidobacteria in patients older than 65 years and who were treated in hopsital with antibiotics. This study was not! able to show, that the intake of probiotics could prevent an antibiotic-associated diarrhea. However also here there were smaller methodical problemns and a single study is indeed not a prove for or against something, therefore metaanlysis are performed from time to time with all suitable studies.
Finally it can be said, that there is indeed some data, that show a positive effect, however then there is also some that could not show it and that it is in general difficult, to "prove" something here, as there are so many preparations that are used in studies and additionally with different dosages and duration. However it is also true, that if you yourself state without doubt a positive effect in your daughter and now when stopping it, the symptoms reoccur, then is cannot be denied and the probiotics are beneficial for your daughter.
If she had an infection of the gastro-intestinal tract after stopping the probiotics or if it were the probioitcs, can of course not be said with security, however one can test this again of course, by giving it again and stopping it again and paying attention to the symptoms.
Unfortunately I cannot tell you either, if the data is sufficient for your health insurance, in order that they pay the costs for the probiotics.
I wish you success and hope to have helped you with this.

Best regards,
Dr. Daniela d'Alquen

(1) Kale-Pradhan PB et al. Pharmacotherapy, 2010 Feb;30(2):119-26
(2) Johston BC et al. Cochrane Database Systematic Review, 2011 nov9;(11):CD004827
(3) Hempel S et al. JAMA, 2012 May 9;307(18):1959-69
(4) Pattani R et al. Open Med. 2013 May 28;7(2):e56-67
(5) Allen SJ et al. The Lancet. 2013 Volume 382, Issue 9900, pages 1249-1257

03.01.2015