Probiotics and Prebiotics

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Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find one of our health articles more useful.

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  • Probiotics are defined as "live micro-organisms that confer a health benefit on the host when administered in adequate amounts." The major source of probiotics for humans is dairy-based foods containing intestinal species of Lactobacillus or Bifidobacterium. The most common type used is Lactobacillus acidophilus (also known as one of the "friendly bacteria"), a species of Gram-positive, rod-shaped bacteria often found in the intestinal tract of humans and animals, the human mouth and vagina. It is an anaerobic organism that produces lactic acid which reduces the pH. This may have an inhibitory effect on other organisms, especially candida. The yeast Saccharomyces cerevisiae and some Escherichia coli and Bacillus species are also used as probiotics.
  • Prebiotics are defined scientifically as "selectively fermented ingredients that result in specific changes in the composition and/or activity of the gastrointestinal microbiota, thus conferring benefit(s) upon host health." They are non-digestible carbohydrates (mainly oligosaccharides and non-starch polysaccharides) which act by promoting the growth and/or activity of probiotic bacteria in the gut. The most common are fructo-oligosaccharides (FOS), inulin and galacto-oligosaccharides. They are found in various vegetables and fruit such as tomatoes, onions, garlic, leeks, asparagus and bananas. Prebiotics are relatively stable and, unlike probiotics, can be relied on to arrive relatively unchanged in the gut despite the presence of digestive enzymes.
  • Synbiotics contain prebiotics and probiotics in the same preparation.

Many commercially available products (eg, yoghurt) are classed as foodstuffs. This means that they escape the rigorous testing for efficacy which is applied to medicines. They have biologically plausible modes of potential action as displacers of pathogens, immunomodulators or local antimicrobial agent secretors. Initial scientific investigation indicates some evidence of usefulness of probiotics in some areas and a definite impetus to continue research into their effects. Doses and recommendations/guidelines for their routine use, however, have yet to be established, pending ongoing research findings. Most benefit has been demonstrated, naturally, for gastrointestinal disorders.

Gastrointestinal disorders

  • Acute infectious diarrhoea. There is some evidence that probiotics shorten duration of acute diarrhoeal illness, and improve symptoms, but the latest review concluded studies varied and more research was needed.[2]
  • Prophylaxis of antibiotic-associated diarrhoea. Studies vary, and ongoing research into the dose of probiotics continues, but there is evidence that probiotics may prevent some antibiotic-associated diarrhoea.[3, 4]
  • Prevention of traveller's diarrhoea.[5, 6]
  • Prevention of Clostridium difficile diarrhoea. There is evidence that probiotics are safe and effective in preventing C. difficile diarrhoea.[7] Public Health England guidelines on C. difficile management, however, do not yet recommend their routine use.[8]
  • Induction or maintenance of remission in Crohn's disease. Evidence suggests little benefit and further research is needed.[9, 10, 11]
  • Induction and maintenance of remission in ulcerative colitis. There is possibility of benefit, but evidence is equivocal and further research is needed.[12, 13]
  • Pouchitis in patients who have undergone surgical resection. Probiotic VSL#3® has been shown to prevent pouchitis, and maintain remission.[14, 15]
  • Irritable bowel syndrome (IBS). There is some evidence that probiotics may improve symptoms of IBS, although ongoing studies are needed to identify which patients benefit, and optimal regimens.[1, 16]The National Institute for Health and Care Excellence (NICE) recommends that if patients wish to try probiotics they should take them at a dose recommended by the manufacturer for a minimum of four weeks.[17]
  • Eradication of Helicobacter pylori. A meta-analysis concluded that fermented milk-based probiotic preparations increased eradication rates in patients on standard eradication therapy by 5-15%.[18].
  • Necrotising enterocolitis. Probiotic therapy reduced both the incidence and severity of this condition in a study of very low birth weight infants.[19, 20]

Other possible uses

Many studies are ongoing into the possible benefits of probiotics in areas including:

There is some evidence that probiotics can affect immune response, and therefore could have potential benefit in any number of clinical scenarios.[24]

There is much interest in the potential for use of prebiotics and synbiotics. Research is being undertaken to look at possible benefit for an enormous number of areas, including:

  • Hepatic encephalopathy. Prebiotics such as lactulose are often used. Minimal hepatic encephalopathy has been shown to be reversed by a synbiotic preparation of probiotics and prebiotics.[25]However, evidence remains equivocal.[26]
  • Immune response. There is some evidence that a prebiotic such as oligofructose in combination with probiotics may boost the immune response.
  • Obesity.
  • Reduction of risk of cardiovascular disease.
  • The metabolic syndrome.
  • Type 2 diabetes mellitus.[27]
  • Reducing the risk of colon cancer. In the experimental setting, one study found the prebiotic inulin reduced the risk of colon cancer.[28]
  • Prevention of eczema and food allergy in infants.[29]

Evidence suggests probiotics are safe in the vast majority. However, there is a small risk of adverse effects, such as sepsis. It is therefore recommended that use of these agents be avoided in those who are immunocompromised, severely debilitated, critically ill or postoperative, as this population is most at risk.[30]There are differences between probiotic/prebiotic agents and regimens both within clinical trials and the way they are used, and these are not likely to be equivalent. Therefore, there is much work to be done before specific clinical guidelines and recommendations can be made.

Meanwhile probiotics and prebiotics exist in everyday food products on supermarket shelves, as well as in capsules, powders and sachets, from a bewildering array of sources. As doctors, we are not yet in a position to give specific evidence-based advice on exactly which product patients should take in which situation.

There is no doubt that prebiotics and probiotics are an interesting group that warrants further investigation. Guidelines were produced in 2010 to guide ongoing research.[31] Studies on one strain of micro-organism cannot be assumed to apply to others, and experimental studies have often not been extended to humans. Many brands of commercially produced probiotics and prebiotics exist, which are not standardised, and there is concern about the applicability of meta-analyses which extend to such heterogeneous groups of subjects, conditions and treatments. The reader should note that this is a fast developing area and new research is published regularly.

Further reading and references

  1. Probiotics and Prebiotics - Global Guidelines; World Gastroenterology Organisation, October 2011

  2. Allen SJ, Martinez EG, Gregorio GV, et al; Probiotics for treating acute infectious diarrhoea. Cochrane Database Syst Rev. 2010 Nov 10(11):CD003048. doi: 10.1002/14651858.CD003048.pub3.

  3. Johnston BC, Goldenberg JZ, Vandvik PO, et al; Probiotics for the prevention of pediatric antibiotic-associated diarrhea. Cochrane Database Syst Rev. 2011 Nov 9(11):CD004827. doi: 10.1002/14651858.CD004827.pub3.

  4. McFarland LV; Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and the treatment of Clostridium difficile disease. Am J Gastroenterol. 2006 Apr101(4):812-22.

  5. McFarland LV; Meta-analysis of probiotics for the prevention of traveler's diarrhea. Travel Med Infect Dis. 2007 Mar5(2):97-105. Epub 2005 Dec 5.

  6. Pham M, Lemberg DA, Day AS; Probiotics: sorting the evidence from the myths. Med J Aust. 2008 Mar 3188(5):304-8.

  7. Goldenberg JZ, Ma SS, Saxton JD, et al; Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children. Cochrane Database Syst Rev. 2013 May 315:CD006095. doi: 10.1002/14651858.CD006095.pub3.

  8. Updated guidance on the management and treatment of Clostridium difficile infection; Public Health England, May 2013

  9. Scaldaferri F, Gerardi V, Lopetuso LR, et al; Gut microbial flora, prebiotics, and probiotics in IBD: their current usage and utility. Biomed Res Int. 20132013:435268. doi: 10.1155/2013/435268. Epub 2013 Aug 7.

  10. Rolfe VE, Fortun PJ, Hawkey CJ, et al; Probiotics for maintenance of remission in Crohn's disease. Cochrane Database Syst Rev. 2006 Oct 18(4):CD004826.

  11. Butterworth AD, Thomas AG, Akobeng AK; Probiotics for induction of remission in Crohn's disease. Cochrane Database Syst Rev. 2008 Jul 16(3):CD006634.

  12. Naidoo K, Gordon M, Fagbemi AO, et al; Probiotics for maintenance of remission in ulcerative colitis. Cochrane Database Syst Rev. 2011 Dec 7(12):CD007443. doi: 10.1002/14651858.CD007443.pub2.

  13. Do VT, Baird BG, Kockler DR; Probiotics for Maintaining Remission of Ulcerative Colitis in Adults (March). Ann Pharmacother. 2010 Feb 2.

  14. Veerappan GR, Betteridge J, Young PE; Probiotics for the treatment of inflammatory bowel disease. Curr Gastroenterol Rep. 2012 Aug14(4):324-33. doi: 10.1007/s11894-012-0265-5.

  15. Holubar SD, Cima RR, Sandborn WJ, et al; Treatment and prevention of pouchitis after ileal pouch-anal anastomosis for chronic ulcerative colitis. Cochrane Database Syst Rev. 2010 Jun 16(6):CD001176. doi: 10.1002/14651858.CD001176.pub2.

  16. Cash BD; Emerging Role of Probiotics and Antimicrobials in the Management of Irritable Bowel Syndrome. Curr Med Res Opin. 2014 Mar 26.

  17. Irritable bowel syndrome in adults; NICE Clinical Guideline (February 2008)

  18. Sachdeva A, Nagpal J; Effect of fermented milk-based probiotic preparations on Helicobacter pylori Eur J Gastroenterol Hepatol. 2009 Jan21(1):45-53.

  19. Alfaleh K, Anabrees J, Bassler D, et al; Probiotics for prevention of necrotizing enterocolitis in preterm infants. Cochrane Database Syst Rev. 2011 Mar 16(3):CD005496. doi: 10.1002/14651858.CD005496.pub3.

  20. Lin HC, Su BH, Chen AC, et al; Oral probiotics reduce the incidence and severity of necrotizing enterocolitis in very low birth weight infants. Pediatrics. 2005 Jan115(1):1-4.

  21. Boyle RJ, Bath-Hextall FJ, Leonardi-Bee J, et al; Probiotics for the treatment of eczema: a systematic review. Clin Exp Allergy. 2009 Aug39(8):1117-27. doi: 10.1111/j.1365-2222.2009.03305.x. Epub 2009 Jul 1.

  22. Yang G, Liu ZQ, Yang PC; Treatment of Allergic Rhinitis with Probiotics: An Alternative Approach. N Am J Med Sci. 2013 Aug5(8):465-468.

  23. Ma YY, Li L, Yu CH, et al; Effects of probiotics on nonalcoholic fatty liver disease: a meta-analysis. World J Gastroenterol. 2013 Oct 2819(40):6911-8. doi: 10.3748/wjg.v19.i40.6911.

  24. Yan F, Polk DB; Probiotics and immune health. Curr Opin Gastroenterol. 2011 Oct27(6):496-501. doi: 10.1097/MOG.0b013e32834baa4d.

  25. Malaguarnera M, Gargante MP, Malaguarnera G, et al; Bifidobacterium combined with fructo-oligosaccharide versus lactulose in the treatment of patients with hepatic encephalopathy. Eur J Gastroenterol Hepatol. 2010 Feb22(2):199-206. doi: 10.1097/MEG.0b013e328330a8d3.

  26. McGee RG, Bakens A, Wiley K, et al; Probiotics for patients with hepatic encephalopathy. Cochrane Database Syst Rev. 2011 Nov 9(11):CD008716. doi: 10.1002/14651858.CD008716.pub2.

  27. Kellow NJ, Coughlan MT, Reid CM; Metabolic benefits of dietary prebiotics in human subjects: a systematic review of randomised controlled trials. Br J Nutr. 2014 Apr111(7):1147-61. doi: 10.1017/S0007114513003607. Epub 2013 Nov 13.

  28. Pool-Zobel BL, Sauer J; Overview of experimental data on reduction of colorectal cancer risk by inulin-type fructans. J Nutr. 2007 Nov137(11 Suppl):2580S-2584S.

  29. Osborn DA, Sinn JK; Prebiotics in infants for prevention of allergy. Cochrane Database Syst Rev. 2013 Mar 283:CD006474. doi: 10.1002/14651858.CD006474.pub3.

  30. Didari T, Solki S, Mozaffari S, et al; A systematic review of the safety of probiotics. Expert Opin Drug Saf. 2014 Feb13(2):227-39. doi: 10.1517/14740338.2014.872627. Epub 2014 Jan 3.

  31. Rijkers GT, Bengmark S, Enck P, et al; Guidance for Substantiating the Evidence for Beneficial Effects of Probiotics: J Nutr. 2010 Feb 3.