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27 Apr 2020
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.
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 also be disturbed by various lifestyle factors including low-fibre diet, travel and infection, but taking antibiotics can be particularly 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, but taking a probiotic alongside an antibiotic can help to reduce the risk of developing the undesirable side effects that occur as a result of the disruption to our gut microbiome, otherwise known as dysbiosis
Common side effects may include6:
Taking probiotics whilst taking antibiotics may help maintain gut microbiome health during antibiotic therapy. Replenishing the gut with beneficial bacteria helps to rebalance the gut microbiome and reduce the risk of developing 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.
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 use of probiotics in antibiotic-associated diarrhoea9. It found that taking probiotics alongside antibiotics may help 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 in helping to support the health of the gut microbiome and reducing digestive upset related to Clostridium difficile-associated diarrhoea10. Health professionals can visit this article in the Professionals site to find out more about Probiotics and Clostridium difficile.
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.
Two strains of probiotics in particular, Lactobacillus 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:
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. Healthcare professionals can read more about the research behind Lactobacillus acidophilus Rosell-52 and Lactobacillus rhamnosus Rosell-11 on the Probiotics Database.
Looking beyond these two strains, a further strain; Bifidobacterium lactis Lafti B94 has been shown in clinical trials to improve the efficacy of triple therapy (which consists of 2 different antibiotics, plus a stomach-acid reducing PPI) in the treatment of H. pylori infection. In a clinical trial involving 194 patients12 with diagnosed H. pylori, participants were divided into 3 groups. The groups were given either standard triple therapy alone, triple therapy plus a placebo, or the triple therapy plus Bifidobacterium lactis Lafti B94. After treatment, the pathogen eradication rate was 86.8% in the probiotic group vs just 70.8% (combined average) across the other two groups that did not receive the probiotic alongside their treatment. Additionally, those in the probiotic group had fewer side-effects, such as diarrhoea, from the combined medications, and therefore a lower treatment discontinuation rate.
The study author summarised: "When taken alongside H. pylori eradication therapy (PPI plus antibiotics) Bifidobacterium lactis Lafti B94 has been shown to significantly reduce incidence of antibiotic associated symptoms such as diarrhoea, abdominal pain and loss of appetite compared to placebo (Cekin, 2017)."
The extensive research behind the two previously mentioned Lactobacillus 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.
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.
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.
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.
Lactobacillus acidophilus NCFM® has been demonstrated in a randomised controlled trial to minimise disturbance to the composition of the gut microbiome when taken alongside antibiotics13. 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®
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 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 resistance14. The over-prescription of antibiotics is a pertinent issue in the UK, with up to 23% of antibiotic prescriptions being deemed “inappropriate” by the NHS15.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 resistance14. 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 16.
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!
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.
You may also wish to read our FAQ, At what time should I take probiotics?