Probiotics, prebiotics or a combination of both? It seems they can all help reduce the side effects of using antibiotics in their unique way. Probiotics can help with some acute symptoms, such as antibiotic-associated diarrhoea,[1] especially in children.[2] Prebiotics, in the form of dietary fibre, can help rejuvenate the diversity of the microbial environment.[3] Combining the two may improve your natural resistance (read immunity) to opportunistic microbes [4] moving forward as well. Let’s take a more detailed look at some of the fundamental elements, how you can take control and recover from antibiotic use.
Sometimes an antibiotic prescription is unavoidable; for most, it’s when you’ve got an infection that isn’t getting better.
It’s the middle of the night, and you’re awake with that familiar feeling in your stomach. The risk you took during dim sum last night has not paid off. There’s no choice but to retreat to the toilet as quietly as possible and try not to wake anyone up. You’ve graciously received what I call a “Hong Kong blessing”, more commonly known as food poisoning.
For most, the symptoms last for 24 hours, some loose bowels, even vomiting. Sudden, sharp, but short. This time though, things don’t seem to be getting better. The day off from work hasn’t solved anything; the old out of date probiotics in the fridge didn’t work, and even Dr Google is recommending you seek help.
Salmonella infections, urinary tract infections, sinus infections and lower respiratory tract infections such as bronchitis all require antibiotic intervention, and after the trip to the outpatient clinic at your closest hospital, your current Hong Kong blessing does too.
So, what explains that feeling of dread after receiving a prescription that you know will help you feel better?
The answer is that sometimes antibiotic treatment can cause more harm than good.
Studies show that the impact of antibiotic use varies from decreased bacterial diversity (lower numbers of species recover post-treatment) to opening the door to opportunistic bacteria that can outgrow our normal bacteria, affecting the microbiome as a whole.[5]
The side effects can be slightly acute and sudden, with some people experiencing allergic reactions to antibiotic administration. Symptoms such as anaphylaxis, hives and trouble breathing can occur within one to two hours of taking the initial dose.[6]
Interestingly, allergic symptoms can present after a more extended period, around four to five days after the first dose. In some cases, the symptoms may not be an allergy at all. For example, the morbilliform skin rash, which can develop within 5 and 14 days of antibiotic treatment, can be caused by an interaction with viral infections, such as Epstein Barr Virus (EBV) or Infectious Mononucleosis (IM), and can easily be misdiagnosed as an allergy.[7]
Ok, I’m not painting the best picture here, but wait, things get a little more concerning -antibiotic resistance is a severe problem.
To properly define that, the WHO “declares antibiotic resistance to be one of the top 10 global public health threats facing humanity”.[8]
The O’Neill report released in the UK defined this predicting that by 2050 (think your children or grandchildren in their 30s), antibiotic-resistant infections will potentially claim 10 million lives a year, overtaking cancer (8.2 million lives a year).
Estimates from the CDC suggest that over 70% of the bacteria responsible for the 2,000,000 infections acquired in US hospitals are resistant to at least one commonly used antibiotic.[9]
This video gets shown to my patients all the time:
These unintended outcomes compound when antibiotics are incorrectly prescribed or not taken properly.
Numerous studies show inappropriate prescriptions of antibiotics from primary care practice reaching up to 50% in the United States [10] [11] [12] and similar levels across Hong Kong.
This incorrect use of antibiotics isn’t just on the side of the prescribers. An investigation into the knowledge, attitudes and behaviour towards antibiotics in Hong Kong showed that 30% of the public would expect or request antibiotic prescriptions for upper respiratory tract infections, such as the common cold, but 40% would not finish the whole course.[13] A behaviour that significantly amplifies the long-term damage that antibiotics can cause.
Self-medication on the side of the patient can also be a problem. In a survey of Hong Kong medical practitioners in 2019, up to 83% of those interviewed (1043 in total) felt as if self-medication of antibiotics is an essential driver of antibiotic resistance.[14] The WHO echoes this narrative as well, especially, it seems, in the southeast Asian region.[15]
It’s not all bad though, antibiotics have saved countless lives, including yours at some stage, and will probably again.
To contextualise this further, 80% of staph infections ended up being fatal before antibiotics. Human life expectancy between 1944 and 1972 increased by eight years, an increase largely attributed to antibiotics.[16] To be fair, the end of the second world war might have helped too, but it is challenging to disagree about the powerful effect antibiotics have had on medicine.
So how can you play a role in recovering from antibiotics if you do take them?
I think I got a bit distracted. Let’s get back to the subject – What to do next when you have to take antibiotics.
One of the first things you can do, as stated above, is to take the entire course prescribed. Not doing so contributes to antibiotic resistance, but worse still may not get you better.
Antibiotics can find it challenging to reach some regions of the body, such as the sinuses, more than others. This difficulty can often result in longer courses recommended, so an effective outcome is achieved. Not completing the prescription can result in the infection not being adequately treated, most often leading to another course of antibiotics being necessary.
Specific probiotic species, such as Saccharomyces boulardii, can help with acute side effects of antibiotic use like antibiotic-associated diarrhoea.
Antibiotic-associated diarrhoea (AAD) can present differently depending on the type of antibiotic you’ve used. Sometimes it can occur earlier, perhaps during the course or, unknown to most, after a delayed response. It can be uncomfortable and affects children regularly. A lesser-known species of probiotic can help.
Never heard of S.boulardii?
Well, this form of probiotic is a little different from the rest. It’s what commonly referred to as a beneficial yeast. S.boulardii has ten controlled trials (that’s great!) on preventing antibiotic-associated diarrhoea, where eight of the ten trials showed significant effectiveness in preventing AAD.[17] Of these eight trials, S.boulardii was given concomitantly with antibiotics or up to seven weeks post the dose (to capture the delayed onset), showing consistent results across the board.
Probiotics can also help build resilience towards some of the opportunistic bacteria and yeast that can develop after antibiotic use
Antibiotics increase the risk of opportunistic infection from other bacteria, but early animal studies also increase opportunistic viral infections like the flu.[18] In some cases, the infections that develop are resistant to antibiotics,[19] creating further problems. Together with this, articles going back as far as 1966 highlight the mechanisms by which antibiotics increase our naturally occurring amounts of undesirable yeast such as C.albicans [20]
In other cases, antibiotic use decreases microbial diversity by up to 25%.[21] This decrease can lead to what’s called intestinal dysbiosis or, more commonly, leaky gut.
Enter our probiotic species. If you’re new to what a probiotic is, here is the definition. Probiotics are live microorganisms that confer a health benefit on the host when administered in adequate amounts. [22]
One way that probiotics protect us from overgrowths of C.albicans and other opportunistic bacteria is their ability to create “bacteriocins.”
Lactobacilli species are especially good at this. Bacteriocins produced by bacteria have a lethal effect on many different classes of bacteria, including the ones that happen to form when the opportunity arises, such as Staphylococcus aureus.[23]
It’s not just Lactobacciili species that help with this but your Bifidobacterium too. The bifidobacteria are particularly good at blocking bacteria setting up shop in your digestion when it gets there; something referred to as “colonisation” or “adhesion.”
In practical terms, your probiotic should have a good spread of Lactobacilli and Bifidobacterium and be kept in the fridge. Remember, part of how we identify probiotics is that they are alive—cool temperatures mostly below 24°C, keep probiotics living. Always choose brands that need to be refrigerated, especially if you live in more equatorial cities, such as Hong Kong or Singapore, where it can be a little warmer.
Another critical tip around probiotics and concomitant use with antibiotics are to make sure you separate the doses of both by a minimum of two hours. Once again, in more practical terms, this could mean taking your antibiotic doses at breakfast and dinner with the probiotic after lunch.
Are there dietary choices that can help boost recovery from antibiotics?
The easy answer is yes. More precisely, though, it’s a combination of what you eat and what you don’t eat.
Let’s focus on what to eat first – prebiotics in the form of dietary fibre. It’s a simple choice, but for most people, difficult to achieve at optimal levels daily. It’s suggested that most of us should increase our fibre intake by around 50% within the western world.[24]
This insufficient consumption is quite alarming when you place fibre into our dietary currency framework. Especially a form of currency the body uses to manage our weight, insulin sensitivity, digestive health, levels of inflammation, mental and cardiovascular health.[25]
Current experiments in animals suggest that a low fibre diet can delay recovery from commonly used antibiotics.[26]
When considering getting prebiotic fibre from your diet, a key mantra is “all prebiotics are forms of dietary fibre, but not all dietary fibre is prebiotic.”
Meaning that more focused dietary choices can make a huge difference.
Prebiotics, in the form of dietary fibre, play a critical role in the balance of the digestive system by providing the resources to create short-chain fatty acids (SCFAs).
SCFAs help maintain the digestive tract’s integrity, referred to as intestinal barrier integrity and decrease inflammation in the lining of digestion. Significantly, when looking at antibiotic recovery, SCFAs modulate the immune system and specific regions of digestion, suppressing the growth of opportunistic bacteria and yeast such as C.albicans.[27] SCFAs also promote the development of important probiotic bacterial species such as lactobacillus and bifidobacteria, which come together to form a significant component of our microbiome.[28]
Soluble fibre such as inulin, found in globe artichoke, leeks, asparagus, oats and soybeans, help to increase the levels of these SCFAs.[29] Adding these foods throughout your antibiotic course and the proceeding weeks can bolster the chances of your digestion finding the balance it needs post-antibiotic use.
But what about what you don’t eat, and how does that make a difference to your antibiotic recovery?
It’s not surprising to hear artificial sweeteners aren’t going to help. Worse still, preliminary research from the University of Queensland suggests that commonly used artificial sweeteners such as saccharin, sucralose, aspartame, and acesulfame potassium may increase the exchange of antibiotic genes between bacteria making them harder to clear in the future.[30]
In 2018, a study covering the same sweeteners mentioned above found their effect on the bacteria in the digestive system to be “toxic” in nature.[31] Not something you want to be doing when the digestive system is already trying to recover from something else.
So, what do I do if I’ve had antibiotics and want to improve my recovery?
We all get the odd Hong Kong blessing where food poisoning or other forms of infection leave us with no other option but to use antibiotics. That may not be a bad thing; remember that people would die of superficial infections before antibiotics!
If you find yourself in this situation, you can do some key things to take charge of your recovery, and here is the executive summary.
Look for a broad-spectrum probiotic that’s in the fridge. Choose foods that give you high amounts of prebiotic soluble fibre and eliminate artificial sweetener consumption.
Hope it helps!
References
[1] Guo Q, Goldenberg JZ, Humphrey C, El Dib R, Johnston BC. Probiotics for the prevention of pediatric antibiotic-associated diarrhea. Cochrane Database of Systematic Reviews 2019, Issue 4. Art. No.: CD004827. DOI: 10.1002/14651858.CD004827.pub5
[2] Yan T, Goldman RD. Probiotics for antibiotic-associated diarrhea in children. Can Fam Physician. 2020;66(1):37-39.
[3] Johnson LP, Walton GE, Psichas A, Frost GS, Gibson GR, Barraclough TG. Prebiotics Modulate the Effects of Antibiotics on Gut Microbial Diversity and Functioning in Vitro. Nutrients. 2015;7(6):4480-4497. Published 2015 Jun 4. doi:10.3390/nu7064480
[4] Kasatpibal N, Whitney JD, Saokaew S, Kengkla K, Heitkemper MM, Apisarnthanarak A. Effectiveness of Probiotic, Prebiotic, and Synbiotic Therapies in Reducing Postoperative Complications: A Systematic Review and Network Meta-analysis. Clin Infect Dis. 2017;64(suppl_2):S153-S160. doi:10.1093/cid/cix114
[5] Langdon A, Crook N, Dantas G. The effects of antibiotics on the microbiome throughout development and alternative approaches for therapeutic modulation. Genome Med. 2016;8(1):39. Published 2016 Apr 13. doi:10.1186/s13073-016-0294-z
[6] Blumenthal KG, Peter JG, Trubiano JA, Phillips EJ. Antibiotic allergy. Lancet. 2019;393(10167):183-198. doi:10.1016/S0140-6736(18)32218-9
[7] Australian Society of Clinical Immunology and Allergy (ASCIA). Antibiotic allergy clinical update. ASCIA, 2014. Available from: www.allergy.org.au/health-professionals/hp-information/asthma-and-allergy/allergic-reactions-to-antibiotics(Accessed Jun, 2015).
[8] https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance, viewed 18th June 2021.
[9] https://www.fda.gov/drugs/information-consumers-and-patients-drugs/battle-bugs-fighting-antibiotic-resistance, viewed 12/06/2021.
[10] Centers for Disease Control and Prevention (CDC). Office-related antibiotic prescribing for persons aged ≤14 years — United States, 1993—1994 to 2007—2008. MMWR Morb Mortal Wkly Rep. 2011;60(34):1153-6.
[11] Pichichero ME. Dynamics of antibiotic prescribing for childrenexternal icon. JAMA. June 19, 2002;287(23):3133-5.
[12] Shapiro DJ, Hicks LA, Pavia AT, Hersh AL. Antibiotic prescribing for adults in ambulatory care in the USA, 2007–09external icon. J Antimicrob Chemother. 2014;69(1):234-40.
More references!
[13] Lam TP, Lam KF, Ho PL, Yung RW. Knowledge, attitude, and behaviour toward antibiotics among Hong Kong people: local-born versus immigrants. Hong Kong Med J. 2015;21 Suppl 7:S41-S47.
[14] https://www.chp.gov.hk/en/static/103680.html, viewed 18th June 2021.
[15] Nepal G, Bhatta S. Self-medication with Antibiotics in WHO Southeast Asian Region: A Systematic Review. Cureus. 2018;10(4):e2428. Published 2018 Apr 5. doi:10.7759/cureus.2428
[16] https://dash.harvard.edu/bitstream/handle/1/8889467/Gottfried05.html?sequence=2, viewed 18th June 2021.
[17] McFarland LV. Systematic review and meta-analysis of Saccharomyces boulardii in adult patients. World J Gastroenterol. 2010;16(18):2202-2222. doi:10.3748/wjg.v16.i18.2202
[18] Bradley KC, Finsterbusch K, Schnepf D, et al. Microbiota-Driven Tonic Interferon Signals in Lung Stromal Cells Protect from Influenza Virus Infection. Cell Rep. 2019;28(1):245-256.e4. doi:10.1016/j.celrep.2019.05.105
[19] Levy J. The effects of antibiotic use on gastrointestinal function. Am J Gastroenterol. 2000;95(1 Suppl):S8-S10. doi:10.1016/s0002-9270(99)00808-4
[20] Seelig MS. Mechanisms by which antibiotics increase the incidence and severity of candidiasis and alter the immunological defenses. Bacteriol Rev. 1966;30(2):442-459. doi:10.1128/br.30.2.442-459.1966
[21] Dudek-Wicher RK, Junka A, Bartoszewicz M. The influence of antibiotics and dietary components on gut microbiota. Prz Gastroenterol. 2018;13(2):85-92. doi:10.5114/pg.2018.76005
[22] Joint FAO/WHO expert consultation. Health and nutrition properties of probiotics in food including powder milk with live lactic acid bacteria. 2001.
[23] Lynne V. McFarland (2000) Normal flora: diversity and functions, Microbial Ecology in Health and Disease,12:4, 193-207, DOI: 10.1080/08910600050216183
[24] Barber TM, Kabisch S, Pfeiffer AFH, Weickert MO. The Health Benefits of Dietary Fibre. Nutrients. 2020;12(10):3209. Published 2020 Oct 21. doi:10.3390/nu12103209
So many references!
[25] Barber TM, Kabisch S, Pfeiffer AFH, Weickert MO. The Health Benefits of Dietary Fibre. Nutrients. 2020;12(10):3209. Published 2020 Oct 21. doi:10.3390/nu12103209
[26] Ng KM, Aranda-Díaz A, Tropini C, et al. Recovery of the Gut Microbiota after Antibiotics Depends on Host Diet, Community Context, and Environmental Reservoirs [published correction appears in Cell Host Microbe. 2020 Oct 7;28(4):628]. Cell Host Microbe. 2019;26(5):650-665.e4. doi:10.1016/j.chom.2019.10.011
[27] Guinan, J., Wang, S., Hazbun, T.R. et al. Antibiotic-induced decreases in the levels of microbial-derived short-chain fatty acids correlate with increased gastrointestinal colonization of Candida albicans. Sci Rep 9, 8872 (2019). https://doi.org/10.1038/s41598-019-45467-7
[28] Venegas-Borsellino, C., Kwon, M. Impact of Soluble Fiber in the Microbiome and Outcomes in Critically Ill Patients. Curr Nutr Rep 8, 347–355 (2019). https://doi.org/10.1007/s13668-019-00299-9
[29] van der Beek CM, Canfora EE, Kip AM, et al. The prebiotic inulin improves substrate metabolism and promotes short-chain fatty acid production in overweight to obese men. Metabolism. 2018;87:25-35. doi:10.1016/j.metabol.2018.06.009
[30] Yu, Z., Wang, Y., Lu, J. et al. Nonnutritive sweeteners can promote the dissemination of antibiotic resistance through conjugative gene transfer. ISME J 15, 2117–2130 (2021). https://doi.org/10.1038/s41396-021-00909-x
[31] Harpaz D, Yeo LP, Cecchini F, Koon THP, Kushmaro A, Tok AIY, Marks RS, Eltzov E. Measuring Artificial Sweeteners Toxicity Using a Bioluminescent Bacterial Panel. Molecules. 2018; 23(10):2454. https://doi.org/10.3390/molecules23102454
