Probiotics and Antibiotics

In 2020, healthcare providers in the USA prescribed 201.9 million antibiotic prescriptions (down from 273.3 million in 2011). This is enough for six out of 10 people to have one prescription a year – or more than 0.6 prescriptions per person.

33.3 million antibiotic prescriptions were given to adults and children younger than 20 and 168.4 million to people aged 20 and older. Women have 62% of all prescriptions.

The CDC estimates that at least 30% of antibiotic prescriptions are unnecessary – given out for infections that do not need antibiotics, such as the common cold or bronchitis. Furthermore, the understanding of and warnings about antibiotic resistance have increased dramatically over the past decade and more than 20 million drug-resistant bacterial infections occur in the USA every year, causing more than 35,000 deaths.[i]

In addition, all antibiotics can cause side effects – including rash, dizziness, nausea, diarrhea, and yeast infections – and the CDC highlights the potentially damaging effects of some classes of antibiotics, including serious allergic reactions, damage to the central nervous system, and Clostridium difficile (C. difficile) infection, which causes severe diarrhea and can lead to more serious complications.

And antibiotics are the leading cause of emergency department visits for adverse drug events (ADEs) in children. These ADEs include allergic reactions and severe swelling beneath the skin.[ii]

The history of antibiotics

Whilst natural antibiotics have been used for millennia, modern antibiotic drugs were first discovered in the late 19^th century when a German physician, Paul Ehrlich, discovered a compound called arsphenamine as a treatment for syphilis. Ehrlich referred to this discovery as chemotherapy and the word antibiotic was first used more than 30 years later.

In 1928, Alexander Fleming then ‘happened upon’ Penicillium notatum, a fungus that killed Staphylococcus bacteria, which was put into mass production by British pharmaceutical companies and gained Fleming (along with two other scientists from Oxford) the 1945 Nobel Prize in Medicine.

Between 1940 and 1962, most of the antibiotic classes we use today were discovered and introduced to the market, but since that time there have been very few new antibiotics developed. Today, the identification of new antibiotic medications has become a significant challenge, at the same time as antibiotic-resistant bacteria are becoming increasingly common.

How antibiotics work

Antibiotics help to stop infections caused by bacteria in or on the body by ‘killing’ the bacteria and preventing them from replicating. There are different types of antibiotics – some are broad-spectrum, meaning that they act on a wide range of disease-causing bacteria. Others are designed to kill certain species of bacteria. Most antibiotics destroy bacteria indiscriminately and do not distinguish between those that are causing disease and the ‘helpful’ bacteria in the gut.

When an infection is potentially life-threatening, such as meningitis, antibiotics are administered intravenously to be able to act as quickly as possible, bypassing the digestive system and being absorbed directly into the bloodstream. For less severe infections, such as urinary tract infections (UTIs) or bacterial vaginosis (BV), antibiotics are administered orally. Bacterial skin infections are often treated with topical antibiotics, which are applied directly at the point of visible infection.

Broad-spectrum antibiotics are often taken orally and must be broken down (digested) in our gastrointestinal tract before being absorbed into our bloodstream to travel throughout the body destroying ALL bacteria in their path, including the commensal bacteria in our microbiome.

As a result, taking antibiotics orally can quickly lead to an imbalance in the gut microbiota, known as dysbiosis. This may lead to digestive symptoms and potentially to disease, as the microbiome may not return to its ‘normal’ state following the removal of the infection.

This destruction of the bacterial balance may give the pathogenic species and strains a chance to overcome the helpful bacteria, which can lead to some of the side effects of antibiotics. These mainly impact the gut and include antibiotic-associated diarrhea (AAD), Clostridium difficile diarrhea, nausea, loss of appetite, vomiting, stomach cramps, and fungal infection, such as Candida albicans (thrush). They may also include fatigue and allergic reactions and can lead to permanent changes in the structure of the microbiome.

What about probiotics?

Over the past two decades, there has been increased interest in the role that probiotics might have in supporting the gut microbiome – acting as proxies (substitutes) for our natural beneficial bacteria and helping to maintain a healthy bacterial balance in our digestive tract.

Whilst the word anti-biotic means ‘against life’, the word pro-biotic means ‘for life’, suggesting that probiotics are important in helping to balance the microbiome against the impact of antibiotics – as antibiotics kill the bacteria, probiotics help to replace them.

Our gut bacteria (microbiome) are fundamental to our health and have a wide range of functions in our body, including anti-inflammatory and immune influence, providing essential nutrients, defending against pathogens, and supporting the structure of the gastrointestinal tract. As a result, maintaining a balance of ‘good’ to ‘bad’ bacteria is key to health and probiotics are useful, if not essential, both alongside and following a course of antibiotics.

A large body of research supports this view, showing that taking probiotics alongside antibiotics can help to reduce the adverse effects of the antibiotics on the gut bacteria. Studies have also shown that taking probiotics alongside antibiotics can support the effectiveness and reduce the side effects of the antibiotics.

Our own research has shown that ProVen Probiotics are specifically helpful in supporting a reduction in C. difficile diarrhea in patients taking antibiotics.[iii] We have also undertaken two studies showing the benefits of probiotics when taken alongside and following antibiotics – preventing disruption of the microbiome and helping to reduce the number of pathogenic bacteria following antibiotic intake (compared with a group not taking probiotics).

Our Cambridge Clostridium difficile study showed that only 46% of patients supplemented with our probiotics were positive for C. difficile toxin, compared to 78% of patients in the placebo group (those taking an identical, inactive capsule).

The ProVen antibiotic trials studied the effect of probiotic supplementation on the intestinal microbiome following antibiotic therapy.

The first study showed that the number of ‘good’ bacteria remained stable in those taking the probiotics and the overgrowth of potentially harmful bacteria was reduced both during and following the course of antibiotics.[iv]

The second study showed a significant reduction in the numbers of Candida albicans fungi and potentially pathogenic bacteria at the end of antibiotic therapy, and there was no increase in antibiotic-resistant bacteria in those taking the probiotics (whilst this was seen in the placebo group).[v]

Answering your questions about probiotics and antibiotics

As experts in the gut microbiome, we understand the relationship between antibiotics and probiotics and receive many questions on this subject every week. We have answered the main ones below.

Why are probiotics given with antibiotics?

Probiotics are not always given alongside a course of antibiotics, but, in our opinion, they should be.

Should I take probiotics twice a day while on antibiotics?

It may be helpful to take a higher dose of probiotics when taking a course of antibiotics and taking them at two separate times (at least two hours away from the antibiotic doses) can help to maintain balance in the gut.

Should probiotics be taken when a person is taking antibiotics?

Some experts recommend taking probiotics immediately following a course of antibiotics, but our research has shown that taking probiotics both alongside and following antibiotics can reduce the adverse effects of the antibiotics on the gut bacteria, helping to maintain a healthy balance of bacteria in our digestive tract.

Studies have also shown that taking probiotics alongside antibiotics can help to support the effectiveness and reduce the side effects of the antibiotics, helping to ensure the full course is completed.

How long should you wait to take probiotics after antibiotics?

Our research shows that probiotics should be taken both alongside and following a course of antibiotics – there is no need to wait until the antibiotic course is finished to start the probiotics. Taking the probiotics daily when taking the antibiotics (though not at the same time) can help to prevent the overgrowth of pathogenic bacteria species and thus reduce the potential for antibiotic-associated gut issues.

We recommend taking the probiotics at least two hours away from the antibiotics to help to ensure that the bacteria are not killed by the antibiotics.

How long should you take probiotics to help rebuild the gut after finishing antibiotics?

We recommend taking probiotics for at least two weeks after finishing a course of antibiotics to help to re-establish the natural balance of the gut microbiome. You may wish to take them for longer if you have taken particularly strong antibiotics over a long period of time.

What are the best probiotics to take with antibiotics?

We recommend taking a probiotic that is supported by research showing its effectiveness in supporting the gut microbiome whilst taken alongside antibiotics. Our ProVen Probiotics have been shown in clinical studies to do this when taken at 25 billion CFUs per day alongside the course of antibiotics.

How do I protect myself from an upset stomach when taking antibiotics?

The key is to eat a healthy diet that includes lots of prebiotic and probiotic foods and to take a probiotic supplement that can help to replace and rebalance the good gut bacteria that are impacted by the antibiotics.

What should I avoid while on antibiotics?

We recommend avoiding sugar and processed foods as these can provide food for pathogenic bacteria species. Alcohol is also best avoided as this can impact the effectiveness of the antibiotics, as can dairy products, and particularly milk, if taken at the same time as the antibiotics.

Will probiotics cancel out the effectiveness of antibiotics?

No, probiotics have no effect on the effectiveness of antibiotics and some studies have shown that they may even support their effectiveness.

Antibiotics can impact the effectiveness of the probiotics, killing off some of the friendly probiotic bacteria and this effect can be offset by taking the probiotics at least two hours away from antibiotic doses.

What should I eat and drink to stay healthy when on antibiotics?

We recommend a varied, healthful diet that supports bacterial balance and includes the following:

• Support gut bacteria balance by eating fermented foods daily – they contain huge numbers and varieties of probiotic species and can help to support the microbiome. Include kefir, sauerkraut, kombucha, kimchi, natural yogurt, and pickled vegetables.
• Feed these microbes (bacteria) with fibrous prebiotic plant foods – including leafy green vegetables, garlic, onions, leeks, unripe bananas, and Jerusalem artichokes.
• Eat foods that support gut health generally – including bone broth, stewed apples, flaxseed, and healthy fats, such as coconut oil, olive oil, and avocado.
• Reduce intake of all forms of sugar and processed foods as these feed the pathogenic strains of bacteria.
• Drink 2-3 liters of water every day to ensure you remain hydrated.

What about ProVen Probiotics – can I take them with antibiotics?

The answer to this question is a resounding YES – ProVen Probiotics can be taken both alongside and following a course of antibiotics and we have undertaken a number of studies that show the effectiveness of our probiotics in helping to maintain microbiome balance and prevent overgrowth of the ‘bad’ bacteria species.

[i] https://www.thelancet.com/article/S0140-6736(20)32063-8/fulltext

[ii] https://www.cdc.gov/antibiotic-use/stewardship-report/pdf/stewardship-report-2018-508.pdf

[iii] Plummer S et al 2004. Clostridium difficile pilot study: effects of probiotic supplementation on the incidence of Clostridium difficile diarrhea. Int Microbiol, 7:59-62

[iv] Madden JAJ et al 2005. Effects of probiotics on preventing disruption of the intestinal microflora following antibiotic therapy: A double-blind, placebo-controlled pilot study. Int Immunopharmacol 5:1091-1097

[v] Plummer S et al 2005. Effects of probiotics on the composition of the intestinal microbiota following antibiotic therapy. Int J Antimicrob Agents 26:69-74