Gut Health

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Evidence Based

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This article contains scientific references. The numbers in the parentheses (1, 2, 3) are clickable links to peer-reviewed scientific papers.

Should You Take Probiotics with Antibiotics?

Written by Dr. Michael Ruscio, DC on February 1, 2020

Written by Dr. Michael Ruscio, DC on February 1, 2020 — Reviewed by Noora Alakulppi

The surprising benefits of combined therapy.

If you leave your doctor’s office with a prescription for antibiotics, you may have very mixed feelings. Of course, you want to clear up an infection, but at what cost to the beneficial bacteria in your gut microbiome?

In the story of modern medicine, antibiotics play the role of both hero and villain. Few other drugs have saved so many lives. However, antibiotics also play a part in the growing epidemic of gut dysbiosis and the litany of chronic health conditions that result from poor gut health.

So, if you must take a course of antibiotics, probiotic supplements are a great way to combat negative side effects. Plus they have lots of other health benefits.

A big question for patients is whether they should take probiotics and antibiotics at the same time. Some people suggest that it’s pointless to take probiotics and antibiotics together since the antibiotics will “kill all the good probiotic bacteria”. While that may make sense intuitively, recent studies show that probiotics and antibiotics actually work in partnership.

Probiotics Make Antibiotics More Effective

Rather than canceling each other out, research shows that taking probiotics and antibiotics together is more effective than taking antibiotics alone.

The most relevant study to show this effect is a systematic review of 20,215 patients with H. pylori infections [1]. Patients who took probiotics and antibiotics together had better results than patients who only took antibiotics. Lactobacillus acidophilus and Saccharomyces boulardii are the probiotic strains at the top of the list for effectiveness in these studies. But keep in mind that these two strains are among those most commonly used in research.

There is also research to show that probiotics and antibiotics are more effective together for SIBO and other gut infections:

• One study of 40 patients with SIBO showed more than double the success rate for eradicating SIBO for those taking a combination of S. Boulardii and metronidazole (an antibiotic) when compared to those taking metronidazole alone.[2]
• 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. [3]

Bottom line: Probiotic co-administration with antibiotics tends to enhance treatment results.

Probiotics Reduce Antibiotic Side Effects

Antibiotics work by killing harmful bacteria that cause infections. Most antibiotics are broad-spectrum, meaning they kill a lot of different types of bugs. This broad action makes them useful for a lot of different types of infections and it’s also why they end up killing good bacteria too.

Antibiotic side effects are caused by the loss of beneficial bacteria and resulting dysbiosis. Dysbiosis leads to:

• Growth of pathogenic infections
• A poorly modulated immune system
• Inflammation

Antibiotic side effects can be long-lasting, especially with repeated antibiotic treatments. Probiotics can be very helpful in restoring the healthy balance of gut bacteria. A large number of studies back this up. Let’s look at a few examples:

Probiotics Correct Dysbiosis Caused by Antibiotics

A systematic review of 63 trials examined all the available research into probiotic use for dysbiosis [5]. In healthy subjects who experienced a disturbance in their microbiota after antibiotic use, 83% of subjects experienced recovery in their microbiota after taking probiotics.

Once again we see Lactobacillus acidophilus and Saccharomyces boulardii at the top of the list for effectiveness in this review.

Probiotics Resolve Antibiotic-Associated Diarrhea

Antibiotic-associated diarrhea is one of the most common side effects of antibiotic therapy and is caused by the dysbiosis that impairs normal gut function and allows harmful bacteria to proliferate.

One of the best studies into the benefits of probiotics for antibiotic-associated diarrhea comes from the prestigious  Journal of the American Medical Association [6]. This meta-analysis reviewed 82 randomized control trials and found:

• Probiotics work well to prevent and treat antibiotic-associated diarrhea
• All probiotic strains used in the studies were found to be effective, including Lacto-bifido blends, Saccharomyces boulardii, and Bacillus (soil-based) strains.

Clostridium Difficile Infections

Researchers also see promising results when probiotics are used for serious Clostridium difficile infections.

C. difficile is a bacterial infection that is indeed “difficult” to deal with. It takes advantage of disruptions in the microbiota, grows quickly and can be difficult to eradicate. C. difficile infections are typically found in hospital patients and those on long-term antibiotic therapy. C. difficile can lead to life-threatening diarrhea and inflammation of the colon.

A meta-analysis of research involving 6851 patients shows that probiotics are a useful and safe prevention strategy for C. difficile infections. Researchers recommend probiotics for patients taking 2 or more antibiotics and in hospital settings [7]. Similar recommendations have also been made for pediatric patients [8].

Is There a Case Against Taking Probiotics with Antibiotics?

Recently, 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 turns out that there’s one study that questions the value of taking probiotics and antibiotics together [9]. In this study of 21 patients, 8 patients received probiotic therapy, 7 patients received no treatment and 6 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 are looking for health insights from research, it’s important to follow the overall trends rather than focus narrowly on one study. So, if we compare the evidence for taking probiotics after antibiotic treatment:

• A meta-analysis of 63 research trials shows that subjects had 48% less antibiotic-associated diarrhea after taking probiotics [10].
• A single study found probiotics to be less effective (for 8 patients) than no treatment at all (for 7 patients) [11].

It’s clear that this one small study doesn’t stand up again a much larger meta-analysis of 63 studies. This is the reason a meta-analysis is the gold standard for research.

Bottom line: Be careful about science-based claims you read on the internet. Marketers often cherry-pick studies to support their position.

The Best Way to Combine Probiotics with Antibiotics

I highly recommend taking probiotics with antibiotics. Here’s some tips on how to get the most from your probiotic supplement when taking antibiotics.

Don’t Go Strain Shopping

It’s not necessary to find the one right probiotic strain for your specific health condition.

That’s because all probiotics have a similar synergistic effect of balancing the gut microbiota, modulating the immune system and reducing inflammation.

Lactobacillus/Bifidobacterium blends and Saccharomyces boulardii are the two categories of probiotics that are used most often in research. Soil-based probiotics are a third category of probiotics used in research, however less frequently. One very large meta-analysis compared results for 82 different studies and found no difference in results across the three probiotic categories [12]. Most of the research trials used a blend of probiotic strains.

While there are a lot of different probiotic strains, all you really need to know are the three main probiotic categories. Learn more in my Probiotics Starter Guide.

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. 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 [13].
• The same study found two common problems in probiotic supplements: 1) low concentration of viable cells and 2) the presence of undesired (potentially harmful) organisms [13].
• Another study found only half of the probiotics examined had the specific strain listed on the label [14].
• 43% of the probiotics in another study contained less than half the amount of probiotic listed on their labels [15].

If a company follows quality assurance practices, a probiotic supplement will meet its label claims and not contain potentially harmful organisms.

Want to know what to look for in a quality probiotic supplement? Read my Probiotics Starter Guide.

Take Probiotics When it’s Convenient for You

Some would recommend taking probiotics at least two hours away from antibiotics to reduce any potential die off. 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 them together than not at all.

For Maximum Effects, Try This Probiotic Protocol

The difference between success and failure with probiotics often comes down to either:

• Establishing balance in your gut microbiome
• Failing to establish balance in your gut microbiome

The key difference here is that many people don’t seem to achieve this balance with just one strain of probiotic.  Some lucky people do, but for many, one probiotic won’t suffice. After many years of trying different approaches, I’ve found this protocol to be most effective:

Probiotic Triple Therapy

• Try a quality formula probiotic from each of the 3 probiotic categories; take all three together: 
  • Lacto-bifido blend
  • Saccharomyces boulardii
  • Soil-based probiotics
• Monitor your symptoms for 3-4 weeks
  • If you’re improving, stay on Probiotic Triple Therapy until your improvements have plateaued.

• Once you’ve seen your maximum improvement (you’ve plateaued), stay here for about a month to allow your gut and immune system to calibrate to these new improvements.
  • Then reduce your dose and find the minimal effective dose.  Stay on the minimal effective dose.

Maintain Your Supplement Schedule, Even if You Eat Probiotic Foods

One way to add probiotic bacteria to the gut is through diet. A number of fermented foods, such as kefir, kimchi, and Lacto-fermented sauerkraut, in addition to many types of yogurt, are rich in probiotics. However, as you can see in this chart, it’s difficult to eat enough fermented foods to get a therapeutic dose.

If you are taking a course of antibiotics, I highly recommend probiotic supplements. If you want to enjoy the benefits of fermented foods, eat these in addition to taking probiotics.