Taking probiotics with antibiotics

Dr Aisling Dwyer MB BCh BAO (Medicine, Surgery and Obstetrics), MSc (Personalised Nutrition)​

Key Facts about Probiotics and Antibiotics covered in this article

  • Antibiotics deplete the populations of natural friendly bacteria that live in our gut, known as the gut microbiome. This may result in side effects such as diarrhoea, nausea, indigestion and low energy. 
  • Probiotics can support digestive health in those taking antibiotics. 
  • Rather than waiting until after the antibiotic course, it's best to take a probiotic supplement which has been designed to take alongside antibiotics, to help maintain balance in the gut microbiome. 
  • Antibiotic resistance is becoming increasingly common, exacerbated by patients not competing antibiotic courses. Taking probiotics with antibiotics may help to prevent side effects and enable individuals to complete the full course of antibiotics.
  • Lactobacillus acidophilus Rosell-52  and Lactobacillus rhamnosus Rosell-11 are two probiotic strains shown to reach the gut alive even when taken at exactly the same time as antibiotics. Health professionals can visit these strains' entries in the Probiotics Database: Lactobacillus acidophilus Rosell-52 and Lactobacillus rhamnosus Rosell-11 
  • The best time to take the probiotic Lactobacillus acidophilus Rosell-52 and Lactobacillus rhamnosus Rosell-11 is at breakfast time, regardless of when the antibiotic is recommended to be taken.
  • If taking other probiotic strains with antibiotics, advice is dependent on the supplier but standard recommendation is to wait at least 2 hours after your antibiotics before taking probiotics.
  • It is best to select strains which have been extensively researched alongside antibiotics.

Lady in pharmacy holding pills

Probiotics and Antibiotics In-Depth

There is no doubt that antibiotics have an essential role to play in modern medicine in preventing and curing bacterial infections. They have saved millions of lives worldwide since their development and mass distribution in the 1940’s. Bacterial infections are no longer the most common cause of death in the modern world, predominantly as a result of the action of antibiotics1. However, in recent times it has become increasingly recognised that antibiotics negatively affect our gut microbiome2.

What happens to our gut microbiome when we take an antibiotic?

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 energy3,4,5. A balance is required between beneficial microbes and more harmful microbes that naturally colonise the gut. This balance can be disturbed by various lifestyle factors including low-fibre diet, travel and infection, among others.

Taking antibiotics can be detrimental to our gut microbiome. Whilst effective in killing pathogenic bacteria (see Glossary entry for pathogens) antibiotics are essentially non-selective and can also deplete the beneficial bacteria residing in the gut. This is thought to contribute to the development of diarrhoea, constipation and/or vaginal thrush when taking an antibiotic. In certain cases, this disruption to our gut microbiome can result in an overgrowth of unwanted, pathogenic bacteria  such as Clostridium difficile. 

Of course, in active infection the benefits of taking antibiotics far outweigh the associated negatives. Taking a probiotic alongside an antibiotic can help to mitigate the undesirable side effects that occur as a result of the disruption to our gut microbiome,  otherwise known as dysbiosis (Glossary definition: dysbiosis).

What are the side effects of taking antibiotics?

Common side effects may include6:

  • Loss of appetite
  • Bloating
  • Nausea
  • Indigestion
  • Abdominal pain 
  • Fatigue, feeling low on energy or ‘wiped out’
  • Antibiotic-associated diarrhoea 

Why take a probiotic with an antibiotic?

Taking probiotics whilst taking antibiotics may help reduce the overall damaging effects antibiotics have on the gut microbiome. Replenishing the gut with beneficial bacteria helps to rebalance the gut microbiome and prevent the development of the common side effects of antibiotics. The NHS has recognised the beneficial effects of probiotic supplementation7. When prescribed antibiotics, many individuals now choose to supplement their natural bacteria with a probiotic supplement. Your local pharmacist may even recommend probiotics when dispensing antibiotics.

Infographic: Probiotics With Antibiotics

Antibiotic-associated diarrhoea (ADD) is one of the most common side effects, with a prevalence of between 5 to 35%, depending on the type of antibiotic8 taken. A meta-analysis of 23 studies carried out in 2012 (focusing on contrasting and combining results from multiple studies) supported the preventative effects of probiotics in antibiotic-associated diarrhoea9. It found that taking probiotics alongside antibiotics were an effective method to reduce the risk of developing diarrhoea. One particular form of AAD is Clostridium difficile infection, which manifests as chronic diarrhoea and in severe cases, colitis. This is of particular concern in the elderly and can sometimes be fatal. 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 for preventing Clostridium difficile-associated diarrhoea10. Health professionals can visit this article in the Professionals site to find out more about Probiotics and Clostridium difficile. 

Can I take probiotics with antibiotics?

Yes. Extensive clinical research suggests that particular strains of probiotics can be taken alongside antibiotics, rather than separately. Health professionals can read this article about research using probiotics alongside antibiotics.

What are the best probiotics for while on antibiotics?

Two strains of probiotics in particularLactobacillus acidophilus Rosell-52 and Lactobacillus rhamnosus Rosell-11, have been tested in numerous clinical trials ALONGSIDE antibiotics and were found to reach the gut alive. They can safely be taken AT THE SAME TIME as antibiotics. The recommended use for a supplement containing this probiotic combination is as follows:

  • Take one capsule daily with breakfast, until antibiotics course is finished, and preferably for one week after.
  • Continue taking until pack is completed and add a second pack if the antibiotic treatment lasts more than one week.

In clinical trials involving individuals undergoing antibiotic treatment for Helicobacter pylori infection, taking Lactobacillus acidophilus Rosell-52 and Lactobacillus rhamnosus Rosell-11 strains alongside antibiotics enhanced the efficacy of the antibiotic treatment11.

Do probiotics survive to reach the gut alive?

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

mixed pills on a plate

Will any probiotic work?

If you are taking a probiotic other than the two Lactobacillus strains mentioned above, it is best to wait 1 to 2 hours after taking your antibiotics before taking the probiotic supplement. 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 on a daily basis, before your digestive system is upset by a longstanding microbial imbalance.

When might other probiotics be appropriate?

Children

Children aged 1 year and over can also take Lactobacillus acidophilus Rosell-52 and Lactobacillus rhamnosus Rosell-11, which have been trialled in this young age group. However, parents may wish to seek a supplement especially formulated for children’s gut health.

Women with intimate health issues?

If you are a woman taking antibiotics for an intimate health issue, it might be worth considering probiotic strains which are well researched for women's intimate health, such as Lactobacillus reuteri RC-14® and Lactobacillus rhamnosus GR-1®. Health professionals can visit the Probiotics Database to read more about the research using these strains; Lactobacillus reuteri RC-14® and Lactobacillus rhamnosus GR-1®.These strains are often used alongside antibiotics for vaginal infections, but are best taken 2 hours away from the medication.

When taking long term antibiotics?

Lactobacillus acidophilus NCFM® has been demonstrated in a randomised controlled trial to minimise disturbance to the composition of the gut microbiome when taken alongside antibiotics12. This can be useful when antibiotics are being taken for longer than two weeks. However, it is recommended to take this probiotic strain 2 hours away from an antibiotic, rather than at the exact same time.To find out more about the research using this strain, health professionals can visit its entry in the Probiotics Database: Lactobacillus acidophilus NCFM®

Do probiotics disturb antibiotic functioning?

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

The over-prescription of antibiotics and antibiotic resistance

The emergence of antibiotic resistance is a concerning public health issue. The World Health Organisation (WHO) published a report1, analysing data from 114 countries, and calling resistance to antibiotics a 'major global threat'. They state that simple, common infections thought to pose little threat today, could become killers again in the future, due in large part to antibiotic resistance. In light of this, steps must be taken to slow the progress of antibiotic resistance, and to change the way we use and prescribe antibiotics. Over-prescription and over-use of antibiotics are significant contributing factors to the development of antibiotic resistance13. The over-prescription of antibiotics is a pertinent issue in the UK,  with up to 23% of antibiotic prescriptions being deemed “inappropriate” by the NHS14.Healthcare practitioners can read further information about the over-prescription of antibiotics here.

.Failure to complete a full course of antibiotics is also believed to contribute to antibiotic resistance13. Unpleasant side effects are often cited as a cause for unfinished antibiotic courses. Probiotics are being used increasingly to help reduce these effects and allow patients to complete their medication. Health professionals might be interested to read more about the use of probiotics against antibiotic resistance.

Alternatives to antibiotics would of course be interesting to explore but ideally in the case of a bacterial infection, this should be under the supervision of a healthcare practitioner. It is worth considering that antibiotics are not always necessary, for example in the case of viral infections, antibiotics will remain ineffective (because antibiotics, by nature, target bacteria). There are also arguably a number of minor bacterial infections that have the potential to resolve naturally without having to rely on an antibiotic. Of note, up to 42% of uncomplicated urinary tract infections may clear spontaneously within 48 hours, especially when helped along with plenty of water 15.

Probiotics vs Antibiotics? You’re asking the wrong question.

The question of whether someone should be taking a probiotic or an antibiotic is commonly asked. The answer, in short, is that it isn't a question of either/or! but instead, whether a probiotic should be taken in addition to, or alongside, an antibiotic. The answer to this question is, in most cases, yes!

Is it ever a question of probiotics OR antibiotics?

There are some conditions where those afflicted may prefer trying natural interventions first. Acne is a very common skin issue where antibiotics are often prescribed as a treatment by a general practitioner or dermatologist. In a 2011 literature review, it was determined that there is sufficient supportive evidence to suggest that gut microbes, and the health of the gastrointestinal tract itself, may be contributing factors in acne vulgaris 3. You may like to read our FAQ about probiotics and skin health. However, this decision should always be made in line with a doctor’s consent.

cartoon image probiotic with antibiotic

Important tips for supporting general health whilst on antibiotics

  • Eat fermented or prebiotic foods. They can help rebalance the gut microbiome and improve gut health after a course of antibiotics.
  • Avoid refined sugary foods, as these feed the harmful bacteria and yeasts which often overgrow due to antibiotic use.
  • Avoid alcohol, even if not contraindicated with your course of antibiotics. Alcohol can also disrupt the gut microbiome and negatively impact immune function, which may hinder your body's efforts to fight infection.
  • Ensure you complete your course of antibiotics. Unpleasant side effects can make it difficult to continue taking antibiotics, but probiotics could help manage these side effects and make it possible for you to finish the prescribed course. This, in turn, can help reduce the risk of antibiotic resistance.
  • Eat a healthy diet. Don't let the antibiotics do all the work - include a selection of immune-boosting foods containing vitamin C and other antioxidants, including citrus fruits and green leafy vegetables.

In Conclusion

  • Take probiotics with your antibiotics instead of waiting to finish your course of antibiotics.
  • If taking Lactobacillus acidophilus Rosell-52 and Lactobacillus rhamnosus Rosell-11 consider taking them with breakfast. These two strains can be taken at the SAME time as your antibiotic.
  • If taking a different probiotic or live cultures supplement, wait at least 2 hours after your antibiotics before taking probiotics.
  • It is important to always follow the advice from your doctor, and always take and finish a course of antibiotics as prescribed.
  • If you have already finished a course of antibiotics before being recommended a friendly bacteria supplement, better late than never; by all means take a probiotic now! For next time, you know you can take them during as well as after.
  • It simply isn't a question of probiotics OR antibiotics - it's a question of probiotics AND antibiotics.

You may also wish to read our FAQ, At what time should I take probiotics?

References

1.        Achievements in Public Health, 1900-1999: Control of Infectious Diseases. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4829a1.htm. Accessed April 16, 2020.

2.        Yoon MY, Yoon SS. Disruption of the gut ecosystem by antibiotics. Yonsei Med J. 2018;59(1):4-12. doi:10.3349/ymj.2018.59.1.4

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.        Antibiotics - Side effects - NHS. https://www.nhs.uk/conditions/antibiotics/side-effects/. Accessed April 15, 2020.

7.        Probiotics - NHS. https://www.nhs.uk/conditions/probiotics/#diarrhoea. Accessed April 15, 2020.

8.        Mcfarland L V. Epidemiology, Risk Factors and Treatments for Antibiotic-Associated Diarrhea Antibiotic complications Antibiotic-associated diarrhea Clostridium difficile Epidemiology Diarrhea, risk factors. 1998;98102:292-307. http://www.karger.com.

9.        Videlock EJ, Cremonini F. Meta-analysis: Probiotics in antibiotic-associated diarrhoea. Aliment Pharmacol Ther. 2012;35(12):1355-1369. doi:10.1111/j.1365-2036.2012.05104.x

10.     Goldenberg JZ, Ma SSY, Saxton JD, et al. Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children. Cochrane Database Syst Rev. 2013;2013(5). doi:10.1002/14651858.CD006095.pub3

11.     Johnson-Henry KC, Mitchell DJ, Avitzur Y, Galindo-Mata E, Jones NL, Sherman PM. Probiotics reduce bacterial colonization and gastric inflammation in H. pylori-infected mice. Dig Dis Sci. 2004;49(7-8):1095-1102. doi:10.1023/B:DDAS.0000037794.02040.c2

12.     Engelbrektson A, Korzenik JR, Pittler A, et al. Probiotics to minimize the disruption of faecal microbiota in healthy subjects undergoing antibiotic therapy. J Med Microbiol. 2009;58(5):663-670. doi:10.1099/jmm.0.47615-0

13.     Ventola CL. The antibiotic resistance crisis: causes and threats. P T J. 2015;40(4):277-283. doi:Article

14.     Up to 1 in 5 antibiotics may be prescribed inappropriately - NHS. https://www.nhs.uk/news/medication/1-5-antibiotics-may-be-prescribed-inappropriately/. Accessed April 16, 2020.

15.     Falagas ME, Kotsantis IK, Vouloumanou EK, Rafailidis PI. Antibiotics versus placebo in the treatment of women with uncomplicated cystitis: A meta-analysis of randomized controlled trials. J Infect. 2009;58(2):91-102. doi:10.1016/j.jinf.2008.12.009