Taking Antibiotics? The Benefits and Side Effects You Need to Know

Intro:

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Dr Ruscio:

Hi, everyone. This is Dr. Michael Ruscio. I just want to make a quick preface that the audio that you’re about to listen to is actually the audio compendium to a video, which has appeared both on our YouTube channel and on our Instagram page for your convenience. We want to always release the audio version of a video here on the podcast. However, it’ll be evident in some videos, more so than others, that the visual aids may be heavily referenced and leaned on. In some cases, having a depiction of a concept can be very helpful in portraying and making comprehendible that concept. So in any case, if you are listening to this and you want the visual aids, please see our YouTube and/or Instagram page so you can have access to those. Okay. And here we go to the audio for today’s video.

Dr Ruscio:

Not all antibiotics are equal. Some have worse side effects than others and some are actually quite helpful. Let’s detail what antibiotics you should be, perhaps, the most cautious with, which ones seem to offer the most benefit with the least risk, and also one terrible piece of advice that healthcare consumers need to be aware of. And when you avoid this terrible piece of advice, you see there is one well-studied, simple fix to mitigate—or even prevent—some of the negative side effects that can occur from antibiotics. Hi, this is Dr. Michael Ruscio and let’s examine this very important topic, which is confusing to patients, understandably so, and there is a middle ground here to be struck.

Dr Ruscio:

The tide thankfully has turned in such a direction where people are not looking at antibiotics as a risk-free intervention. This is good. The Pez-like dispensing of antibiotics, probably a bad idea. However, and especially if you’re more educated regarding your health, you might have swung your opinion too far anti-antibiotic. And what I’m hoping to do here is help you see there is a middle ground. So let’s go over, firstly, the most commonly used antibiotics: penicillins for things like ear and sinus infections, strep throat; Keflex for skin infections; fluoroquinolones are also used for respiratory tract infections, salmonella, and prostatitis; and there are also your Azithromycins, oftentimes used for acne and STDs; tetracyclines, which are used for rosacea, H pylori; Bacterim, which if you’re a woman who’s had a UTI, you may have used this; Clindamycin for abdominal infections, respiratory infections, vaginal and pelvic infections; Flagyl or Metronidazole used for parasitic protozoal or even also for vaginal and pelvic infections.

Dr Ruscio:

That’s an overview of, certainly not all, but some of the most commonly used. Now, which ones are most helpful? Little bit debatable, and also depends on what you have going on, right? If you have a life threatening infection and the only option is a antibiotic with a high side effect profile, the Pro/Con lays in favor of using that, of course. But just as a general overview here, Rifaximin, which is FDA approved for IBS (irritable bowel syndrome) and has been shown to treat SIBO (small intestinal bacterial growth) has interesting effect and merit in the sense that it’s not absorbed, it’s in fact localized to the gut and therefore can treat this gut overgrowth SIBO and has really no systemic effect. Flagyl can also be helpful, especially for resistant parasites, H pylori, and also for SIBO. And amoxicillin, Augmentin is the most commonly prescribed antibiotics, at least according to a recent CDC report.

Dr Ruscio:

So these are the ones that you may want to fret the least about when using. However, which ones are most likely to cause side effects? Well, all antibiotics have potential for some degree of antibiotic resistance and for reactions. Of course, the more you use them, the more problematic they may become from both a resistance and reaction perspective. Fluoroquinolones are probably the class that has the longest side effect profile, clindamycin and tetracyclines.

Dr Ruscio:

Now, what are the most common side effects from antibiotics? Well, as you can probably imagine, digestive upset, diarrhea, abdominal discomfort, nausea, vomiting, but also dizziness, skin rashes, antibiotic resistance, and (even in some cases of penicillins) severe allergic reactions. Now Clindamycin in particular does pose a risk for antibiotic-resistant Clostridium difficile and other super infections like certain strains of yeast. So this should be noted. And […] the most robust, if you will, side effect profile is from the Fluoroquinolones with heart arrhythmias, aortic aneurysms, neuropathies (nerve damage), and other neurological complications like insomnia, anxiety, or even paranoia.

Dr Ruscio:

And so what is the terrible piece of advice? Well, it’s to avoid probiotics. A 2018 study appearing in the journal Cell that was mainly an observation and mechanism study found a delay in recovery of the microbiota if one used probiotics after taking antibiotics. And what was most frustrating was this article that appeared in the BBC. And I wanted to read you a little bit of this. The reason why really, unfortunately, when there is a finding that goes against the grain that tends to draw the most eyes and the most publicity. And what’s really sad about this is a novel or different finding, let’s say one finding that goes against (let’s say arbitrarily here) 50 other studies finding the opposite, the one different finding tends to get the most press. And this is a problem with news being the vector of healthcare information, because the news isn’t always doing a good job of bringing you the best evidence and the best information.

Dr Ruscio:

And I’m certainly not anti-news, but let’s go into some of the write up here from this article appearing in the BBC. They quote, “it might make sense to or appeal to you to use a probiotic after taking antibiotic,” but they say, “there is scant solid evidence suggesting probiotics actually work if taken this way.” And they continue and they quote a researcher from, again this one study going against the grain of what I’ll show you is a overwhelming number of studies finding the opposite, that they have found a “potentially alarming adverse effect of probiotics…and that the evidence is mounting that taking probiotics when gut health is weak, is not such a good idea.” And further, they say there aren’t enough studies for any one probiotic that says they work according to a researcher who authored a large meta-analysis from 2012, which was almost 10 years before this article was written.

Dr Ruscio:

So firstly, that should be a red flag. If this is a 2019 article and you’re citing evidence from nearly 10 years ago, that’s a red flag. And this author in their study did find a positive effect of probiotics in helping to reduce the risk of antibiotic-associated diarrhea. That seems encouraging, but due to the variation and some lack of clarity on which specific formulas were used or beneficial, they couldn’t make a pinpoint recommendation.

Dr Ruscio:

So what they’re saying…There’s two ways you can look at this. You can say this meta-analysis (which is a study of studies), in this case looking at 82 studies, couldn’t conclude one probiotic was best. You could say, well, therefore we’re not going to use any probiotics. Or you could say, well, if we couldn’t say one was best, but we did find that probiotics helped to prevent antibiotic associated diarrhea, you could also conclude that it doesn’t matter what specific probiotic you use because benefit has been demonstrated for multiple different probiotics. This is hugely important for the healthcare consumer to understand.

Dr Ruscio:

Also, as this article continues, “since 2012 the evidence in support of probiotics after antibiotics hasn’t moved a great deal.” In eight years the science on probiotics hasn’t moved a great deal? Anyone who is plugged into PubMed—which I am and which our research team is—spends at least 45 minutes a night, a night reading through the newly published abstracts on probiotics. This is a burgeoning field of study. So again, this is really, unfortunately, a very misleading news piece. So this is a terrible piece of advice because it’s opposite of what the majority of the scientific evidence is finding.

Dr Ruscio:

And let’s look at some of this evidence. Firstly, it’s important to state that this trial and cell was looking at, essentially observations of what happens in the microbiome. Like these thousand odd species of bacteria in your gut and the ratios, but they weren’t looking at the health of the host.

Dr Ruscio:

And this is the most important, right? This is, “well, your bacteria ratios are perfect.” But I’ve got diarrhea and abdominal pain… “Well, good thing your ratios look perfect,” right? This is the challenge. And this is when I think patients get annoyed and, rightfully so, they should, when a doctor says your tests are normal [even though you] feel terrible, right? So we want to look at clinical trials. This is what looks for: how are you feeling, did we prevent antibiotic-associated diarrhea, abdominal pain, what have you?

Dr Ruscio:

So this researcher’s finding is antithetical because it’s looking at the fine assessment of the ratios of bacteria, which to tell you the truth, doesn’t really matter. What really matters is does this person have side effects after the antibiotic? That’s really the most important thing to look at. And this is what I want to take you through.

Dr Ruscio:

Now in summary, there is very good evidence that has found less diarrhea, less side effects overall, reduced risk of Clostridium difficile, and improved clearance of whatever infection is being treated when probiotics are administered alongside antibiotics. What’s my evidence for this? Well only the poultry Journal of the American Medical Association, wherein 63 trials were summarized and they found that subjects had 48% less antibiotic-associated diarrhea after taking probiotics.

Dr Ruscio:

And this isn’t the only data point […] there are two other meta-analyses, but I want to circle back to the prevention of side effects. And I first want to address how two meta-analyses (summaries of clinical trials) have found that probiotics help antibiotics work better. One meta-analysis found that there was a doubling of the eradication rate of SIBO when probiotics were used alongside antibiotics. And a 2020, so current (remember that body of probiotic research that hasn’t moved much?) well a 2020 trial or meta-analysis found a 10% enhancement of clearance of H pylori when using probiotics along with antibiotics.

Sponsor:

Hi, everyone. If you are in need of help, we have a number of resources for you. “Healthy Gut, Healthy You”, my book and your complete self-help guide to healing your gut. If you’re not a do-it-yourselfer there is the clinic—the Ruscio Institute for Functional Medicine—and our growing clinical and supporting research team will be happy to help you. We do offer monthly support calls for our patients where I answer questions and help them along their path, health coaching support calls every other week, and also we offer health coaching independent of the clinic for those perhaps reading the book and/or looking for guidance with diet, supplementation, etc. There’s also the store that has our Elemental Diet line, our probiotics, and other gut health and health-supportive supplements. And for clinicians, there is our FFMR—the Future of Functional Medicine Review—database which contains case studies from our clinic, research reviews, and practice guidelines. Visit DrRuscio.com/resources to learn more.

Dr Ruscio:

Also, I’d like to hear your comments. Have you experienced antibiotic-associated side effects? Have you gotten conflicting advice in terms of probiotics? Please let me know in the comments.

Dr Ruscio:

So what probiotics should you use? And then I’m going to tie it to how we can use probiotics to prevent the side effects from antibiotics. But let’s start with this overview. Really any probiotic will help. And this is what I think confuses some myopic researchers. They’re unable to accept that multiple different probiotics all show benefit. And because of that, they can’t recommend a probiotic because until they can say, “one is the best,” then they won’t recommend one.

Dr Ruscio:

And this, again, is the wrong way of looking at it. This has been demonstrated in the model of small intestinal bacterial overgrowth that different probiotics all have efficacy. And there seems to be no resistance by researchers to say, “well, you can use Rifaximin, you can use Flagyl,” but for whatever reason with probiotics, there’s a great degree of hesitancy. Perhaps because they’re not prescription. I’m not exactly sure.

Dr Ruscio:

What I, and what we at the clinic, recommend is using three different types of probiotics in conjunction. We call this probiotic triple therapy. The short backstory is if you look at the probiotic literature, you see the majority of probiotics fall into one of three types: blends of lactobacillus and bifidobacterium, a Saccharomyces boulardii, or a soil-based probiotic. So in the first category, again lactobacillus and bifidobacterium, this is something like Visbiome or VSL3. The Saccharomyces boulardii is something like Florastor. And then the soil-based or spore-forming will contain a number of usually bacillus species.

Dr Ruscio:

So in the clinic we had been experimenting with one or the other, and then we had said, well, if one helps someone, and we’ll discuss further, if one probiotic can show these benefits, why not two? And turns out that it seemed that the two were better than the one. And eventually we found our way into using all three together via this probiotic triple therapy. And the evidence supporting this also further outlines the benefits, the merits that probiotics have to reduce antibiotic-associated side effects. Okay, so remember we said there’s three different types. There’s your lactobacillus and bifidobacterium blends. Now, to the researchers’ credit who get confused by this, you will see different formulas, right? There might be one with five species, there might be one with 10, but they all share this signature of a predomination of lactobacillus and bifidobacterium species.

Dr Ruscio:

Now, again, from that body of literature that hasn’t moved much since 2012, a 2021 meta-analysis of 42 randomized control trials found a 46% reduction in diarrhea when using any variety of different lactobacillus and bifidobacterium predominated probiotics. This is the most common one you’ll find when you pick up a probiotic on the shelf in the health food store, and look at the label. However, we also discuss Saccharomyces boulardii and a 2021 randomized control trial found a better ability to eradicate H pylori and less side effects when Saccharomyces boulardii was used along with antibiotics in quadruple therapy for H pylori. And then finally, the newer kid probiotic on the block, a 2018 meta-analysis of six randomized control trials and another 2020 review paper found that soil-based probiotics reduced diarrhea and hospital stays from C diff infection when used alongside antibiotics.

Dr Ruscio:

So I hope it’s clear to see that while, yes, we can’t say this one probiotic with a specific species and strain and dose is what you should use, that doesn’t mean that you should just say, “well, guess I’m not going to use probiotics.” Because you could literally reduce your risk of being in the hospital, of having diarrhea, of having side effects, and improve the clearance rate of whatever infection—if you’re treating an infection—that the antibiotic is being administered for.

Dr Ruscio:

So I want to give the researcher in this study whatever defense I can, however, language like that, that is sloppy, probably well intentioned but I think sloppy, leads people to avoid probiotics and suffer the side effects and consequences. So it literally does harm people. So it is important, then we get this right. And same thing for the science health or medical writer here, just a poor job in really doing their research. We discussed a number of trials that display benefit, and these are good trials, these are again the meta-analyses and these are what we want to really be looking at. So, unfortunate.

Dr Ruscio:

If you are looking for some guidelines on dosages of probiotics and how to use them, we have put together our Probiotic Starter Guide. It’s a free resource available in the description of this video. And to recap, some antibiotics are worse than others. This is the Fluoroquinolones, the Clindamycins, and potentially the tetracyclines. The common symptoms are gastrointestinal, dizziness, skin rashing, and antibiotic resistance. Probiotics help by improving diarrhea, other side effects, they improve eradication rate, and they reduce your likelihood of having something like C diff. And remember the advice to avoid probiotics, probably well intentioned…I want to give people the benefit of the doubt but that argument has not been constructed carefully, it’s a bit myopic, and it’s not rooted in assessing the best science. It’s more so in my opinion, a derivative of cherry picking. So please understand that probiotics are very well studied. They’re very safe, and they should be used to help prevent antibiotic-associated side effects and to help you get healthier faster for whatever it is the antibiotic is being used to treat.

Dr Ruscio:

Okay, this is Dr Michael Ruscio. And I very much so hope this helps.

 

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