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The Truth About Taking Probiotics And Antibiotics Together

Written by Dr. Michael Ruscio, DC on September 27, 2021

Written by Dr. Michael Ruscio, DC on September 27, 2021 — Reviewed by Dr. Hannah Hamlin

Optimizing Your Results With Combination Therapy

• Probiotics Make Antibiotics More Effective|
• Probiotics and H. pylori|
• Probiotics and SIBO|
• Probiotics and Bacterial Infections|
• Probiotics and C. Diff|
• Antibiotic Side Effects|
• The Case Against Probiotics with Antibiotics|
• The Best Way to Use Probiotics and Antibiotics|
• Probiotic Foods|
• The Bottom Line|

It’s tempting these days to avoid antibiotics at all costs. After all, they’ve played a part in the growing epidemic of gut dysbiosis, antibiotic resistance, and a litany of other chronic health conditions that result from poor gut health. But, let’s face it, there are some instances when antibiotics are extremely helpful and even life-saving.

If you do need to take an antibiotic to clear an infection, taking probiotics and antibiotics together can help reduce the damage to your beneficial gut bacteria. Plus, probiotics have a lot of other great health benefits too.

Some people suggest it’s pointless to take probiotics and antibiotics together since the antibiotics will “kill all the good bacteria.” While that may make sense intuitively, studies show that probiotics and antibiotics actually work in partnership. In fact, adding a probiotic to your antibiotic protocol has been shown to significantly improve treatment outcomes for a variety of conditions, including SIBO and H. Pylori. Probiotics can also help to reduce or resolve antibiotic-associated side effects like diarrhea. 

In this article, I’ll detail how taking probiotics and antibiotics together can improve outcomes in a number of conditions and also provide some guidance on how you may want to go about adding probiotics when you’re on an antibiotic.  

Probiotics Make Antibiotics More Effective

Rather than canceling each other out, research shows the use of probiotics and antibiotics together is more effective than taking antibiotics alone. A number of studies have shown these benefits in various conditions, so let’s take a look at the specifics.

Probiotics and Helicobacter Pylori Infection

One of the most relevant studies showing the benefits of taking probiotics with antibiotics is a systematic review of more than 20,000 patients with H. pylori infections 1. Patients who took probiotics and antibiotics together had better results than patients who only took antibiotics. 

Another meta-analysis of randomized clinical trials totaling roughly 6,000 patients with H. pylori infections showed that adding probiotics with antibiotics for H. pylori increased the eradication rate by about 10% 2.

These benefits may be due in part to probiotics being able to make harmful bacteria more sensitive to antibiotics. One non-randomized trial comparing the DNA of antibiotic resistant bacteria in H. pylori patients found the number of expressed antibiotic resistance genes was lower when patients were given Saccharomyces boulardii (a probiotic yeast) in addition to antibiotics 3.

Probiotics and Small Intestinal Bacterial Overgrowth

Taking probiotics with antibiotics for small intestinal bacterial overgrowth (SIBO) has been found to improve the effectiveness of treatment when compared to taking antibiotics alone:

• One study of 40 patients with SIBO showed those taking a combination of S. boulardii and metronidazole (an antibiotic) had more than double the success rate for eradicating SIBO when compared to those taking metronidazole alone 4.
• Another study showed that a combination of probiotic and antibiotic therapy normalized glucose breath tests for 13 out of 15 patients with both SIBO and Crohn’s disease 5.
• Probiotics have been found to be a possible helpful addition to treatment in hydrogen SIBO, particularly in people who have not responded to treatment with antibiotics 6.

Probiotics and Clostridium Difficile Infections 

Researchers also see promising results when probiotics are used for serious Clostridium difficile infections. C. difficile is a bacterial infection that takes advantage of disruptions in the microbiota and can be difficult to eradicate. C. diff infections can lead to life-threatening diarrhea and colon inflammation.

A meta-analysis of research involving close to 7,000 patients shows that probiotics are a useful and safe prevention strategy for C. difficile infections. Researchers recommend probiotics for adult patients taking two or more antibiotics and for those in hospital settings 7. Similar recommendations have also been made for pediatric patients 8.

Overall, the research finds probiotic co-administration with antibiotics to be a safe, non-invasive, and effective way to enhance treatment results. And if you need to be on an antibiotic, probiotics can be your ally in preventing or improving antibiotic-associated adverse effects. Let’s dive into the specifics of how probiotics can help.

Probiotics and Other Bacterial Infections

Two meta-analyses have found that taking probiotics and antibiotics together was 20–23% more effective than taking antibiotics alone for curing bacterial vaginosis (an overgrowth of bacteria in the vagina) 9 10. In addition, probiotics taken alone were 12–30% more effective at curing bacterial vaginosis than antibiotics alone and 100–150 times more effective than placebo 9 10. Essentially, this means you may not even need to take antibiotics at all for bacterial vaginosis, which would help you avoid any gut microbiome disruptions and the potential side effects of antibiotics.

In men with infected semen or prostate secretions, probiotics added to antibiotics cleared the infection 26% more of the time than antibiotics alone 11.

Antibiotic Side Effects

If you’ve ever been on an antibiotic, especially for a longer length of time, it’s likely you’ve experienced some type of adverse side effect like diarrhea, a yeast infection, or gastrointestinal pain.

Antibiotics work by killing harmful bacteria that cause infections, so many of their side effects end up being unintended consequences. Most antibiotics are broad-spectrum, so that means they kill a lot of different types of bugs. While the targeted invaders (like pathogenic bacteria) are being dealt with, your healthy gut flora, as innocent bystanders, are also getting killed. When you lose beneficial bacteria during antibiotic treatment, dysbiosis can result 12.  

Dysbiosis can lead to 13:

• Pathogenic infections from viruses, “bad bacteria”, and fungi 
• Poor immune system function 
• Inflammation 

Antibiotic side effects can be long-lasting, especially with repeated antibiotic treatments. But probiotics can be very helpful for restoring the healthy balance of gut bacteria. A large number of studies back this up, let’s check out the details. 

Probiotics Correct Dysbiosis Caused By Antibiotics

Dysbiosis, or the imbalance of bacteria, can be a common negative effect of antibiotic use. Dysbiosis can impair normal gut function and allow harmful bacteria to proliferate. If you’re worried about an antibiotic disrupting the composition of your gut microbiome in this way, then it makes sense to take probiotics and antibiotics together as they’ve been shown to generally recover the microbiome after the use of antibiotics. 

A systematic review of 29 trials found probiotics added to antibiotics helped to preserve bacterial diversity and restore the composition of gut microbes, including health-related bacteria 14. 

A larger systematic review of 63 trials found Lactobacillus and Bifidobacterium probiotics and S. boulardii to be effective for restoring the gut microbiome after antibiotic use. In fact, 83% of patients with dysbiosis experienced microbiota recovery when using probiotics 15.

Additionally, probiotic, prebiotic, and symbiotic supplements given to babies exposed to antibiotics during a cesarean section or during their first week of life helped to restore their microbes to nearly resemble the gut microbiomes of vaginally born babies 16. This is great news as we now know the extreme importance of the birth method and the first three years of life for establishing the adult gut microbiome.While more research needs to be done on preventing yeast infections that result from antibiotic use specifically, probiotics have been shown to prevent Candida colonization in premature babies, and they’re also as effective as antifungal medications in reducing fungal infections 17 18.

Probiotics Resolve Antibiotic-Associated Diarrhea

Antibiotic-associated diarrhea is one of the most common side effects of antibiotic therapy and is generally caused by dysbiosis. If you have to take antibiotics and want to avoid diarrhea, high-quality research suggests you should take probiotics during your course of antibiotics 19 20. One study found taking probiotics with antibiotics reduced the risk of antibiotic-associated diarrhea by 37% in adults. And high doses were even more effective, with a 46% reduced risk 21. It seems the earlier you start probiotics, the better:

• A randomized controlled trial of kids found starting probiotics within 24 hours of antibiotic therapy to reduce the risk of diarrhea by 35% 19.news
• A meta-analysis of 8 trials found a 29% reduction in antibiotic-associated diarrhea when probiotics were given to elderly patients within 48 hours of starting an antibiotic. There was no difference in the rates of diarrhea when the probiotics were given after 48 hours 20. 

If you can’t get the probiotics started within 24–48 hours of starting an antibiotic, you can and should still start the probiotics. Starting earlier may provide more benefit, but taking probiotics at any point during antibiotic treatment will help to restore gut microbiome balance. Additional research has found:

• Higher doses of probiotics were effective at preventing diarrhea or reducing the duration of diarrhea by one day in children who still got antibiotic-associated diarrhea 22.
• Adding probiotics for longer than 10 days to antibiotic treatment for H. pylori reduced the incidence of gastrointestinal side effects such as diarrhea, vomiting/nausea, and abdominal pain 2.

Probiotics from all three categories were used in these studies. These categories are Lactobacillus and Bifidobacterium blends, Saccharomyces boulardii, and soil-based Bacillus species 2 21 22 23. In other words, whichever type of probiotic you use is likely to provide benefits, and there’s no need to be super specific about the type of probiotic you choose.  But what about people who recommend avoiding probiotics with antibiotics?

Is There a Case Against Taking Probiotics and Antibiotics Together?

I’ve seen some internet articles that warn people against taking probiotics to help with recovery from antibiotic therapy. Where is this advice coming from?

It may come from single small studies, such as one that questioned the value of taking probiotics and antibiotics together 24. In this study of 21 patients, eight patients received probiotic therapy, seven patients received no treatment, and six patients received a fecal transplant. Researchers found that probiotics were less effective for antibiotic recovery than no treatment at all. The fecal transplant brought near-complete recovery in a matter of days.

However, when you’re looking for health insights from research, it’s important to follow the overall trends rather than focusing narrowly on one study. For example, let’s compare the evidence from that small, non-randomized study to a broad meta-analysis of many randomized controlled trials (RCTs), the gold standard type of research.

The large-scale meta-analysis of 63 RCTs showed that subjects had 48% less antibiotic-associated diarrhea after taking probiotics 23. But that one single study involving fewer than 20 patients found probiotics to be less effective (for eight patients) than no treatment at all (for seven patients) 24.

It’s clear that one small, non-randomized study doesn’t stand up against a much larger meta-analysis of 63 gold-standard RCTs. This is the reason the meta-analysis of RCTs is the highest quality type of research.

Overall, be careful about science-based claims you read on the internet. Marketers often cherry-pick studies to support their position.

So now that you know how beneficial taking probiotics and antibiotics together can be, what’s the best way to take them?

The Best Way to Use Probiotics and Antibiotics

If you’re taking antibiotics, I highly recommend taking them with probiotics. And we’ve already seen that starting probiotics early on may provide more benefit, especially when it comes to antibiotic side effects like diarrhea 25 26.

Here are some additional tips on how to get the most from your probiotic supplement when taking antibiotics:

1. There’s no need to go strain shopping. Many different probiotics have been shown to be beneficial when used alongside antibiotics. This is because all probiotics tend to have the same beneficial effects, such as balancing the gut microbiota, modulating the immune system, and reducing inflammation.

• Lactobacillus/Bifidobacterium blends and S. boulardii are the two categories of probiotics that are used most often in research. Soil-based probiotics are a third category that’s been used less frequently but is still a great option.
• One very large meta-analysis compared results for 63 different studies and found no difference across the three probiotic categories for antibiotic-associated diarrhea 23. Most of the research trials used a blend of probiotic strains.

2. Choose a quality probiotic formula. Quality assurance practices do matter. Probiotic manufacturing is not highly regulated, and some label claims do not stand up to scrutiny. If a company follows quality assurance practices, a probiotic supplement will meet its label claims and not contain potentially harmful organisms. Consider the results of these investigations into probiotic quality:

• One study assessed 26 commercial probiotics and found that none fully supported label claims. Some probiotic supplements contained unacceptable microorganisms 27.
• The same study found two common problems in probiotic supplements: low concentration of viable (live) cells and the presence of undesired (potentially harmful) organisms 27.
• Another study found only half of the probiotics examined had the specific strain listed on the label 28.
• 43% of the probiotics in another study contained less than half the amount of probiotics listed on their labels 28.

3. Take probiotics at a convenient time.  Some would recommend taking probiotics at least two hours before or after antibiotics to reduce the potential for the antibiotic to kill the probiotic you just took. You can do this if you want, but if that makes your medication schedule too complicated, just take them together. You’re better off taking probiotics and antibiotics together than not at all.

At this point, you may be wondering if you can just eat probiotic foods and get the same benefits.  Let’s unpack why it’s best to take probiotic supplements when you’re taking antibiotics. 

What About Probiotic Foods?

One way to add probiotic bacteria to the gut is through diet. A number of fermented foods, such as kefir, kimchi, Lacto-fermented sauerkraut, and many types of yogurt, are rich in healthy bacteria. 

However, as you can see in this chart, it’s difficult to eat enough fermented foods to get a therapeutic dose.

If you want to enjoy the benefits of fermented foods, you can eat these as well. However, if you are taking a course of antibiotics, I highly recommend probiotic supplements in order to get the important therapeutic effects of probiotics.

Taking Probiotics and Antibiotics Together is Beneficial

Taking probiotics is a simple and highly effective way to improve your health outcomes when you need to take antibiotics. Probiotics make antibiotics more effective at clearing an infection, but they can also significantly reduce the incidence of undesirable side effects of antibiotics, most commonly diarrhea and gut dysbiosis. 

While some people recommend waiting to take probiotics until after you’ve finished taking antibiotics, current research does not support this. You’ll probably get the best results when you start taking probiotics at the same time your antibiotic therapy starts. While you do need to choose a quality probiotic product, you don’t need to be too specific about which strain you choose or what time of day you take the probiotic.

If you’ve been on prolonged antibiotics, it may be helpful to complete my Great-In-8 Action Plan in Healthy Gut, Healthy You. If you complete this self-help protocol and still struggle with your gut health, reach out to the Ruscio Institute for Functional Health.

The Ruscio Institute has developed a range of high-quality formulations to help our patients and audience. If you’re interested in learning more about these products, please click here. Note that there are many other options available, and we encourage you to research which products may be right for you.