Effectiveness of Saccharomyces boulardii (a probiotic) for antibiotic-associated diarrhea and for C. difficile infection

A good recent review of the effectiveness of probiotics highlights especially the value of Saccharomyces boulardii for diarrhea associated with antibiotic treatments, and for C. difficile infections (a common, and often quite stubborn, gastrointestinal infection). This review, published in 2009, pools data from a number of studies to draw its conclusions. The author first focuses on antibiotic-associated diarrhea, which is a common side effect of many currently used antibiotics, occurring in up to a third of patients being treated. In the second place, the review looks at C. difficile infection and the clinical evidence for the effectiveness of probiotic treatments. In the case of both antibiotic-associated and C. difficile-associated diarrhea, the author concludes that Saccharomyces boulardii has shown effectiveness as a treatment. Among the other findings of this article: probiotic treatments have a very good safety profile and therefore can be recommended widely; and it is very important to treat using probiotics with documented high quality/potency standards in order to insure beneficial outcomes.

Read more about dosage and uses of Saccharomyces boulardii in the NYBC catalog, which now includes two different choices, both from high-quality producers:

Saccharomyces boulardii – Jarrow

and

Florastor – Biocodex

Reference:

McFarland, L. V. Evidence-based review of probiotics for antibiotic-associated diarrhea and Clostridium difficile infections. Anaerobe/Clinical microbiology 15 (2009) 274–280.
Accessed at http://www.idpublications.com/journals/PDFs/ANAE/ANAE_MostDown_1.pdf

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Gut Microbiome in HIV

A recent article, technical as usual, looked at the kinds of bacteria found in the intestines of people living with HIV vs those uninfected (and included one long-term non-progressor who has lived 21 years without treatment and no progression). What they found was described beautifully in this post with embedded video.

The idea presented was that perhaps we can help reduce bodywide inflammation by establishing a more healthy bacterial profile in the gut. An idea we have been talking about for decades!! And indeed, this is why we have proposed the use of agents like glutamine (which help the cells lining the gut called villi to turnover), along with probiotics and prebiotics (fiber and/or beta glucans). These are rather blunt tools but do seem to help improve gut function. We do have some data on the use of probiotics in the management of HIV-related diarrhea and for bacterial vaginosis (and our sister organization, FIAR, is working on a meta-analysis on those data). While these kinds of interventions have some benefit, ultimately, understanding what one’s ideal “microbiome fingerprint” is — what is the balance of different types of bacteria that colonize your gut under uninfected conditions — and figuring out how to replace that may provide a substantial improvement in clinical condition, dramatically reducing bodywide inflammation that may persist even under conditions of antiviral suppression.

See the NYBC website for more information on PROBIOTICS

 

Probiotics Conference Report

Below is a report on a recent conference on one of our favorite categories of supplement–PROBIOTICS.
We aren’t surprised that prestigious scientific organizations like the New York Academy of Sciences devote their resources to spreading the word about Probiotics. Over the last 100 years, these “friendly bacteria” have been the subject of an enormous amount of scientific study, confirming their crucial role in maintaining the human body’s immune system. And we also know that many NYBC members over the years have benefited from use of Probiotics such as the Jarrodophilus line from Jarrow, or Florastor (Saccharomyces boulardii). For a full list of these Probiotics, with indications for their use and dosing recommendations, see the NYBC catalog at PROBIOTICS AT NYBC

Report on
Probiotics, Prebiotics, and the Host Microbiome:
The Science of Translation
Wednesday, June 12, 2013 | 7:45 AM – 6:00 PM
/The New York Academy of Sciences
George M. Carter

This was a day-long series of discussions, with nearly 70 posters that brought together a variety of researchers, clinicians and, of course, pharma reps sniffing around for profits.  And all about the horrors of–BACTERIA! Of course, some bacteria cause disease…but most of them not only don’t, but we need them to live. And there are indeed a lot of them!

These good ones, when they are found in the diet or as a supplement, are known as probiotics, such as acidophilus or bifidobacteria. They are found, for example, in yogurt or other fermented foods. Prebiotics, on the other hand, are substances that help to facilitate the growth of those good bacteria, but are otherwise non-digestible. They include fiber (soluble or insoluble) and agents such as beta glucans, inulin and oligosaccharides.

There seemed to be a general feeling of anticipation as our knowledge grows about the microbes we share—and depend upon for our survival. Various populations of microbes live in distinct communities on and in our bodies. Each bacterium has its own set of DNA, just like each of our human cells (except cells like platelets and red blood cells). All of our human cell  DNA contributes about 25,000 genes. By contrast, if you add up all the “bugs” in and on our bodies, that figure runs into the MILLIONS of genes, recent estimates placing the number at about 8 million. And if you removed all the microbes from your body, aside from killing you, that entire amount of bacteria would weigh up to 3 pounds!

That collection of microbes and their genes and gene-products are known as the microbiome.  This is a complex system of various species of bacteria that interact with the host (us) and other bacteria. They tend to form ecologies at various sites so that the crew found in your nostrils may not be the same as that found in the gut, the vagina, or on the skin, for example. And the patterns of bugs that colonize us are different from person to person to some degree—and even change over the course of a lifetime.

These various types of bacteria are categorized by their taxonomy. Taxa refers to the genus, species and strain of the bacteria; for example, you may have heard of Lactobacillus acidophilus, often found in enriched yogurts. “Lactobacillus” is the genus name and “acidophilus” is the species. These also may be divided into further subtypes known as strains, so one strain is L. acidophilus L1, used to feed cattle to reduce the amount of bad bacteria such as E. coli O157:H7.

And these bacteria are necessary for our survival. They perform a huge number of functions, including producing some vitamins, training our immune systems, blocking bad bacteria from growing, and even altering our moods. They communicate within and between species of bacteria, as well as with our body. Some of them may cause trouble, including Helicobacter pylori (ulcers) and Clostridia difficile (colitis). How best to treat a dysbiosis (=microbial imbalance on or inside the body)  is evolving as we increase our understanding of the relationships and ecologies of these bacterial communities.

The alterations in the nature of these communities arise from the time we are born. If one is born by a Caesarean, one tends to get more of the microbes of the mother’s skin as opposed to the vaginal microbial system that the infant collects during a vaginal birth. Whether this has any longer term clinical impact remains unclear, though some evidence suggests that those born by Caesarean may be at higher risk of allergies or asthma. The microbiota tend to establish themselves as a more adult phenotype by the tender age of 2 or 3.  Some researchers are developing models that look at similarities in the patterns of the microbes such that people are divided into 2 or 3 enterotypes.Although this attempt at classification is still evolving, it may help us see how an individual’s response to or problems with host bacteria can be understood and managed.

Indeed, some of the sessions focused on new discoveries of particular bacteria that appear to be associated with protection from certain diseases, or may be implicated in causing disease. One group discussed their findings of a putative association of Akkermansia muciniphilia with the development of diabetes, while others focused on patterns of the microbiome that might underscore a potential for obesity. Many of the sessions were devoted to research in mice, which was moderately interesting from an academic perspective. Others looked at the inter-relationship between probiotics and brain function as well as “gut feelings” (the gut containing what some have dubbed a second brain’s worth of neuronal innervation).

This raised some  issues abouthow to study these agents in the context of a Food and Drug Administration that is at the least bureaucratically hostile to the study of dietary supplements and currently forbids them to be marketed as preventing, curing or mitigating diseases. Discussion was devoted to these challenges, but I think it failed to get to the heart of the matter, namely, that we need—VERY carefully[1]—to address how to create rulemaking with regard to Investigational New Drug requirements that does not require an absurd level of documentation of safety for products ALREADY on the market and in widespread use!

Other studies in humans can avoid the onerous process of acquiring an IND by using a primary endpoint (what the study seeks to establish) that is more in line with either the supplement’s use as a “medical food” (a very narrow definition), or that seeks to improve outcomes to structure or function of the body (the currently allowed dietary supplement claim).

The frightening prospect, to me, was the pharma reps sniffing around, no doubt seeing how they can “capitalize” on and/or patent products to extract huge profits. The notion of “public-private” partnerships in this arena gives me the horrors as it usually means taking away access except for the wealthy. We’re talking about products found in yogurt that have been used for millennia!

Still, the day also had a couple of remarkable and straightforward studies. The most exciting was the work of a group who helped women in various nations in Africa to produce their own probiotics and yogurt. This had the added advantage of creating an economic opportunity for the women, increasing respect from male householders as they brought in income while also improving health outcomes. This was augmented even more by the addition of a powder of the dried leaves of Moringa, a plant that grows like a weed from South America, throughout Africa, South and Southeast Asia, and which has a good array of micronutrient vitamins and minerals. Not in huge amounts, but fairly comprehensive.

A speaker from Scotland, Mr. Burns, also discussed the kind of “grassroots” organizing that they undertook in Scottish hospitals to translate research into the public health sphere. The point of this exhilarating talk was how to get from the bench to the bedside—in short, he was promoting a very comprehensive strategy for creating awareness among physicians and others, working with district leaders and hospital administrators. Their efforts got them, for example, to adhere more closely to checklists for surgeries and pneumonia management. By requiring and getting more attention to these matters, they were able to successfully, and dramatically, drop death rates. Some of these programs have run now for over 10 years, and involve getting physicians and others to prescribe probiotics or prebiotics and  actually use them in preventing C. diff. or better management of bacterial vaginosis,or management of HIV-related diarrhea!

It was a day packed with information and interesting people. I attended with Dr. Henry Sacks of Mount Sinai School of Medicine, with whom I have been working on a grant from the National Institutes of Health to undertake meta-analyses of various questions relating to the use of Complementary and Alternative Medicine (CAM) approaches to managing HIV disease and ARV side effects. We are finishing up work on our first two questions, the use of a multivitamin/mineral among HIV+ people, and the management of peripheral neuropathy with Cannabis sativa. Our next question, which we are now beginning to work on, is the use of probiotics!

For more information, abstracts and so forth, please visit the NYAS website.

______

Footnote:
[1]  Any changes in IND rulemaking should be careful to avoid opening the floodgates to drug companies using such changes to weaken safety or oversight of new drugs, of course. Accelerated approval has been abused by the companies to push more drugs more rapidly onto the market that are NOT medically superior or addressing a desperate need as antiretroviral drugs were in the mid-90s.

Probiotics found effective for antibiotic-related diarrhea

A recent review article that pooled findings from more than 11,000 patients concluded that probiotics were effective for preventing and treating antibiotic-associated diarrhea. About 30% of people treated with a course of antibiotics develop diarrhea, so this is a significant medical issue. Types of probiotics reviewed include Lactobacillus and Saccharomyces boulardii; both were found effective. See NYBC’s entries under Probiotics for details on how to use.

Reference: Hempel S, et al “Probiotics for the prevention and treatment of antibiotic-associated diarrhea: a systematic review and meta-analysis” Journal of the American Medical Association 2012; 307: 1959-1969

Florastor: a probiotic for many types of acute and chronic diarrhea

For many types of acute and chronic diarrhea, the probiotic Florastor can be recommended as the best natural approach. Florastor is the tradename of Saccharomyces boulardi lyo (lyo = freeze dried, the best means for preserving the effectiveness of this probiotic species; also means that Florastor is shelf-stable at room temperature).

Here are the main indications/conditions for which Florastor/Saccharomyces boulardii has been investigated:

Acute Diarrhea
A controlled study found a significant reduction in symptoms of diarrhea in adults taking 250mg of S. boulardii twice a day for five days or until symptoms were relieved.

Irritable Bowel Syndrome
A placebo-controlled study found that patients with diarrhea due mainly to irritable bowel syndrome (IBS) had a significant reduction in number and consistency of bowel movements.
Suggested dosage is 250mg twice daily.

Inflammatory Bowel Disease
Florastor benefits for inflammatory bowel disease (IBD) include: 1) prevention of relapse in Crohn’s disease patients currently in remission and 2) improvement for ulcerative colitis patients with moderate symptoms. Suggested dosage is three 250mg capsules a day.

Antibiotic-Associated Diarrhea
Some evidence for its usefulness in the prevention of antibiotic-associated diarrhea (AAD) in adults. Suggested dosage: 250mg twice a day with the standard antibiotic course.

HIV/AIDS-Associated Diarrhea
Saccharomyces boulardii was shown to significantly increase the recovery rate of stage IV AIDS patients suffering from diarrhea. On average, patients receiving S. boulardii gained weight while a placebo group lost weight over the 18 month study. There were no reported adverse reaction observed in these immunocompromised patients.

Recurrent Clostridium difficile Infection
Two 500mg doses per day of Saccharomyces boulardii when taken with one of two antibiotics (vancomycin or metronidazole) were found to significantly reduce the rate of recurrent Clostridium difficile (pseudomembranous colitis) infection. However, note that significant benefit was not found for prevention of an initial episode of Clostridium difficile-associated disease.

For more on Saccharomyces boulardii, see the NYBC entry:

Florastor

Note that non-member price is $30, but member price is NOW ONLY $29. (NYBC Membership costs $5, $10, or $25 per year, depending on income.)

Some references (there are many more, since Saccharomyces boulardii is among the most-studied probiotics):
–Höcher W, Chase D, Hagenhoff G (1990). “Saccharomyces boulardii in acute adult diarrhoea. Efficacy and tolerance of treatment”. Münch Med Wochenschr 132: 188–92. 
–McFarland L, Surawicz C, Greenberg R (1994). “A randomised placebo-controlled trial of Saccharomyces boulardii in combination with standard antibiotics for Clostridium difficile disease”. J Am Med Assoc 271: 1913–8. 
–Maupas J, Champemont P, Delforge M (1983). “Treatment of irritable bowel syndrome with Saccharomyces boulardii: a double blind, placebo controlled study”. Medicine Chirurgie Digestives 12(1): 77–9. 
–Guslandi M, Mezzi G, Sorghi M, Testoni PA (2000). “Saccharomyces boulardii in maintenance treatment of Crohn’s disease”. Dig. Dis. Sci. 45 (7): 1462–4. PMID 10961730. 
–Guslandi M, Giollo P, Testoni PA (2003). “A pilot trial of Saccharomyces boulardii in ulcerative colitis”. Eur J Gastroenterol Hepatol 15 (6): 697–8. doi:10.1097/01.meg.0000059138.68845.06. PMID 12840682. 
–Saint-Marc T, Blehaut H, Musial C, Touraine J (1995). “AIDS related diarrhea: a double-blind trial of Saccharomyces boulardii”. Sem Hôsp Paris 71: 735–41. 

Florastor/ Saccharomyces boulardii

Here’s the NYBC summary of recent research on Saccharomyces boulardii, which is available under the tradename Florastor:

Saccharomyces boulardii, sometimes abbreviated Sac. boulardii or S. boulardii, is a very well-researched probiotic, with several hundred peer-reviewed studies to its credit, many from the past two decades. It’s now the first choice among probiotics for antibiotic-associated diarrhea, C. difficile colitis, and “traveler’s diarrhea.” It can also help with irritable bowel syndrome, ulcerative colitis and Crohn’s disease. Here are some recent research highlights:

-Harvard Medical School researchers have identified specific pathways by which Saccharomyces boulardii decreases intestinal inflammatory responses; their 2006 report helps explain the broad range of protective effects that this probiotic exerts in a variety of gastrointestinal disorders. (Sougioultzis S, et al. Saccharomyces boulardii produces a soluble anti-inflammatory factor that inhibits NF-kappaB-mediated IL-8 gene expression. Biochem Biophys Res Commun. 2006 Apr 28;343(1):69-76.)

-A 2006 meta-analysis (combined analysis of multiple individual studies) found that Saccharomyces boulardii was the only probiotic studied that was effective against Clostridium difficile disease, a common form of antibiotic-associated diarrhea. (McFarland L V. Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and the treatment of Clostridium difficile disease. Am J Gastroenterol. 2006 Apr;101(4):812-22.)

-A 2008 study found that Crohn’s patients receiving Saccharomyces boulardii treatment showed significant improvements in intestinal function compared with those given a placebo. (Garcia Vilela E, et al. Influence of Saccharomyces boulardii on the intestinal permeability of patients with Crohn’s disease in remission. Scand J Gastroenterol. 2008;43(7):842-8.)

-An investigation published in 2009 found that, of a variety of probiotics, Saccharomyces boulardii was uniquely able to stimulate production of secretory IgA, the main immunoglobin found in mucus, saliva, and secretions from the intestine and the lining of the lungs, and a main component of the body’s protective mechanism against pathogens. Thus Saccharomyces boulardii may now be credited with an ability to enhance immune function in general. (Flaviano S. et al. Comparative study of Bifidobacterium animalis, Escherichia coli, Lactobacillus casei and Saccharomyces boulardii probiotic properties. Archives of Microbiology, Volume 191, Number 8 / August, 2009.)

See the NYBC entry for more details, including recommended dosages:

http://nybcsecure.org/product_info.php?products_id=217

Supplements for Diarrhea and Malabsorption

We’re reprinting below the NYBC recommendations
for supplements that address the common gastrointestinal
problems of people with HIV:

Diarrhea. This is one of
the most common side effects of
antiretroviral drugs–especially protease
inhibitors. When it occurs, make
sure to drink plenty of (healthy) fluids
to replace electrolytes (potassium,
sodium, and magnesium ions) and
prevent dehydration. Avoid sugary
and/or caffeinated beverages.
One of the simplest remedies: bananas!
Adding a yogurt with active
cultures to your regular diet can also
improve diarrhea. In addition to adding
beneficial flora to your gastrointestinal
tract, yogurt is nutritionally
rich in protein, calcium, riboflavin,
vitamin B6 and vitamin B12.

However, for some, dietary changes may
not be enough to control the diarrhea
Supplements to consider in treating
diarrhea associated with protease
inhibitors include calcium, and glutamine
(up to 20-40 grams daily for
diarrhea while it persists). There are
some clinical data to support these
interventions. A note of caution: calcium
carbonate works fine but should
be avoided if you are using atazanavir
[Reyataz].

If diarrhea is associated with the use
of antibiotics, go probiotic! Use acidophilus,
bifidus or Saccharomyces
boulardii
(Florastor) to control C.
difficile (a problem frequently encountered
with antibiotic use) and to improve gut function.
Use of digestive enzymes may also help to improve
digestion (e.g., lipase, protease, amylase, and
lactase).

Malabsorption is the difficulty in digesting or
absorbing nutrients from food. It’s a widespread
problem among HIVers, and a serious
one at that. HIV disease damages the
guts, where it is estimated that 80%
of the disease “lives,” hindering the
digestive tract’s ability to absorb nutrients
(or meds). Additionally, many
HIVers actually have too little acid
in their stomachs – a little-discussed
condition. This can cause the sphincter
at the opening of the stomach to
fail to close properly, resulting in
GERD: gastro-esophageal reflux disorder.
In general, gut function can be
improved with probiotics such as
acidophilus and bifidus, as well as
2-5 grams of glutamine, taken daily.
Further, digestive enzymes that help
break down fats, carbs and proteins
may be useful in promoting better
absorption. Again, a good diet and
a potent multi are important starting
points!

See the NYBC entries for more detailed
recommendations regarding these supplements:

Glutamine Powder:
http://nybcsecure.org/product_info.php?cPath=49&products_id=128
or Glutamine Caps:
http://nybcsecure.org/product_info.php?cPath=49&products_id=127

Douglas Vegetarian Enzymes:
http://nybcsecure.org/product_info.php?cPath=49&products_id=264
Jarro-Zymes Vegetarian Enzymes:
http://nybcsecure.org/product_info.php?cPath=49&products_id=335

Ultra Jarro-Dophilus (probiotic):
http://nybcsecure.org/product_info.php?cPath=27&products_id=354
Jarrodophilus EPS (No refrigeration needed):
http://nybcsecure.org/product_info.php?cPath=27&products_id=199
Saccharomyces boulardii (Florastor):
http://nybcsecure.org/product_info.php?products_id=217