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Rapid Responses: Rapid Responses published:
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Brewer's yeast and antibiotic associated diarrhoea
- Andy Li (7 June 2002)
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Probiotics - where's the Cons?
- Christopher E Clark (13 June 2002)
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Misleading presentation of pooled odds ratios
- Michael T. Koller (13 June 2002)
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Probiotic Balance
- Bill D. Misner Ph.D. (21 June 2002)
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Probiotoics and unnatural selection
- Mark Battle, Lara Teare, Sue Law and Jamie Fulton (1 July 2002)
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Andy Li, Specialist Registrar Gastroenterology Laboratory, The Rayne Institute, St Thomas' Hospital, London SE1 7EH
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EDITOR- D’Souza and colleague‘s meta-analysis on the use of probiotics in the treatment of antibiotic associated diarrhoea included studies on the use of Saccharomyces boulardii (1). I felt it was important to respond with the observation that brewer’s yeast (Saccharomyces cerevisiae) has also been suggested as therapy for antibiotic associated diarrhoea especially in association with Clostridium difficile colonisation. Apart from a single case report and the observation that both yeasts attenuate Clostridium difficile induced colonic secretion in rats, there is no clinical evidence for the efficacy of brewer’s yeast in either treatment or prevention of antibiotic associated diarrhoea (2) (3). It is important, not to confuse brewer’s yeast and Saccharomyces boulardii as has been pointed out previously (4). 1. D’Souza AL, Rajkumar CR, Cooke J, Bulpitt CJ. Probiotics in prevention of antibiotic associated diarrhoea: meta-analysis. BMJ 2002;324:1361-1364 2. Kovacs DJ, Berk T. Recurrent clostridium difficile-associated diarrhea and colitis treated with Saccharomyces cerevisiae (Baker’s yeast) in combination with antibiotic therapy: a case report. J Am Board Fam Pract. 2000;13:138-140 3. Izadnia F, Wong CT, Kocoshis SA. Brewer’s yeast and Saccharomyces boulardii both attenuate Clostridium difficile-induced colonic secretion in the rat. Dig Dis Sci 1998;43:2055-2060 4. McFarland LV. Saccharomyces boulardii is not Saccharomyces cerevisiae. Clin Infect Dis. 1996;22:200-201 |
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Christopher E Clark, General Practitioner School Surgery, Fore St, Witheridge, Devon EX16 8AH
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This paper reports a meta-analysis of nine randomised controlled trials showing odds ratios in favour of preventing antibiotic associated diarrhoea with probiotics. The case is not proven, however, as noted in the accompanying editorial, and two aspects of this study cast doubt on the suggested benefits. Firstly, the authors' search was limited to Medline and Cochrane. Other databases such as Embase or Cinahl could well have revealed other published studies. To minimise publication bias, there should also have been attempts made to identify unpublished trials by contacting authors and manufacturers and searching the "grey" literature. Unpublished studies tend to have less positive results and their omission can exagerate apparent treatment effects. The other problem is that we are not told of any harms or side effects of treatment. This may be because the original papers reported none but we need to know before making a judgement on the use of probiotics. |
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Michael T. Koller, Research fellow Horten-Zentrum, Universitätsspital Zürich, 8091 Zürich
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In the meta-analysis of D’ Souza et al the pooled odds ratios are shown in a misleading way. Following the convention of the Cochrane Handbook (1), odds ratios or relative risks for unfavourable dichotomous outcomes are less than one, indicating that treatment is better than control. As the authors defined the outcome measure as the percentage of patients without diarrhoea, indicating a “good” outcome, the results favouring treatment should have been greater than one. The authors should either have deviated from the convention or have presented “bad” outcomes (patients with antibiotic associated diarrhoea). (1) The Cochrane Reviewers’ Handbook 4.1.5, Update April 2002, Page 65. http://www.cochrane.org/software/Documentation/Handbook/handbook.pdf |
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Bill D. Misner Ph.D., R & D Director E-CAPS Inc.
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Editors: A single Probiotic does not establish a balance in microbial strains in both upper and lower gastrointestinal tracts. Research that does not replace probiotic "Good" bacteria in both upper and lower tracts fails to restablish microbial balance. Intestinal microbial populations require a controlled balance slightly favoring "Good" over "Bad" bacterial counts. Antibiotics inhibit proliferation of all microbial counts leading to graduated bacterial imbalances favoring harmful "Bad" bacteria proliferation contributing to gastric stress or diarrhea. Ingesting too much "Good" bacteria may also contribute to gastric stress with diarrhea in patients so predisposed. The key to probiotic research as an adjunct to preventing antibiotic-induced diarrhea is balanced supplementation of both upper tract and lower tract microbial bacteria in moderate dose, not excessive. Lactobacillis Acidophilus bacteria predominantly colonize the the upper to lower protions of the small intestine while other forms such as b. Bifidum & b. Longum microbials colonize primarily the lower protions of the small intestine and the large intestine. Combining these strains may help suppress harmful bacteria and the substances they produce along the entire intestinal tract [1-4]. Dose potency at no less 1.5 billion per capsule dose to no more than 5.0 billion per dose needs to be determined before trial against antibiotic medication. Failure to appropriately supply upper tract and lower tract healthful "Good" bacteria strains in moderate dose will result in less than optimal gut bacterial imbalance. Overdosing or taking only a single strain ineffectively examines that probiotic applications as an effective preventative for antibiotic-induced diarrhea. Several probiotic formulations effectively replace losses in both lower and upper tracts and may be recruited to more accurately determine dose potency providing a complete endpoint resolution. REFERENCES [1] Honma, N. New Medicines and Clinics 36(1): 75, 1984. [2] Mitsuoka, T. Medicina 21(8): 1374, 1984. [3] Mitsuoka, T. Clinics and Bacteria 2(3): 55-97, 1975. [4] Mitsuoka, T. J. Jpn. Food Indus. 31(4): 285, 1984. Disclosure Statement: The author discloses competing interests, employed by a Company which markets a probiotic. |
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Mark Battle, Specialist Registrar Directorate of Medicine. Level 8, Derriford Hospital, Plymouth, Devon PL6 8DH, Lara Teare, Sue Law and Jamie Fulton
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EDITOR- We were intrigued by the article by D’Souza and colleagues (1) which evaluates potential agents for the prevention of antibiotic associated diarrhoea; it is well recognised that antibiotic-associated diarrhoea’s full spectrum of activity has an immense impact both in the community and in hospital. In particular, the anti-therapeutic default selection of Clostridium difficile with resultant colitis is associated with a considerable morbidity and mortality. Alteration of the faecal flora holds considerable attraction as a low risk means of preventing or, possibly, treating Clostridium difficile and associated infections (2). Induced dysequilibrium of the colonic flora can be achieved either through supplemental ‘probiotic- loading’ or by therapeutic manipulation. A means of faecal floral manipulation is through the use of lactulose, a synthetic disaccharide that is predominantly used as an osmotic laxative. It is neither absorbed nor metabolised in the upper gastrointestinal tract, but is degraded by the bacterial flora of the proximal colon to organic acids. These acidify the proximal colon and result in a dose-dependent catharsis. Lactulose also has been shown to have several additional properties including an anti-endotoxin effect (3) and alteration of faecal floral patterns(4). This quantitative alteration in faecal floral patterns, with an increase in faecal Lactobacillus acidophilus and a reduction in both coliforms and bacteroides has been confirmed in our own unpublished work. It also is possible that there is a qualitative alteration in bacterial pathogenicity that is due to the use of lactulose as an alternative substrate. There is additional historical evidence of effective treatment of Shigellosis (5) and Salmonellosis (6) with lactulose. A number of risk and host factors have been recognised and identification of those at high risk of antibiotic associated diarrhoea could facilitate targeted pre-treatment with lactulose, or conjoint treatment with lactulose and antibiotics. It is possible that an effective means of gaining rapid benefit might be through a ‘double hit’ with lactulose and a probiotic such as Lactobacillus acidophilus. Additionally, in those who have developed antibiotic associated diarrhoea, lactulose-induced manipulation of the faecal flora may prove to be an effective means of treating the infective cause of the diarrhoea, although there may be some difficulty encountered convincing clinicians to treat diarrhoea with a laxative. 1. D’Souza AL, Rajkumar C, Cooke J, Bulpitt CJ. Probiotics in prevention of antibiotic associated diarrhoea: meta- analysis. BMJ 2002, 324: 1361-4. 2. Barbut F, Meynard JL. Managing antibiotic associated diarrhoea. BMJ 2002, 324: 1345-6. 3. Liehr H, Englisch G, Rasenack U. Lactulose- a drug with anti-endotoxin effect. Hepato-gastroenterology 1980; 27: 356-60. 4. Vince A, Zeegen R, Drinkwater J et al. The effect of lactulose on the faecal flora of patients with hepatic encephalopathy. Journal of Medical Microbiology 1974; 7: 163-8. 5. Levine MM, Hornick RB. Lactulose therapy in Shigella carrier state and acute dysentery. Antimicrobial Agents and Chemotherapy 1975; 8: 581-4. 6. Scevola D, Barbarini G, Concia E, Michelone G, Imo V. Costs and benefits of diagnostic and therapeutic methods in Salmonella infections. Bolletttino dell Instituto Sieroterapico Milanese 1985; 64: 376-80. |
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