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Role of Probiotics in Acute Gastroenteritis: Review
Acute gastroenteritis (AGE) is referred to as inflammation of the mucus membranes of the gastrointestinal tract (1). AGE is characterized by a reduction in the consistency of stools (loose or liquid) and/or an increase in the frequency of evacuations (usually 3 in 24 hours), with or without fever or vomiting. (2) Twelve per cent of all deaths among children under five years of age has been associated with AGE, with even higher rates of AGE-related hospital admissions reported in developing countries. (1) Despite advances in healthcare over the last several decades, acute infectious gastroenteritis remains one of the top causes of mortality in underdeveloped nations. (3)
One of the long-term implications of gastroenteritis on intestinal physiology is that it favors the colonization of atypical microbial species, which can disturb the healthy gut microbiome. Research reveals that gut dysbiosis persists long after infection clearance and is linked to an increased risk of chronic sequels and recurrence. (4) Consistent evidence re-affirms that probiotics improve the gut microflora and prevent gut inflammation by re-establishing the milieu of the gut microbiome, resulting in the amelioration of gut inflammation. Such alterations in the composition and function of the human gut microbiome ultimately positively influence host immunity and neurobiology. (5) The management of acute gastroenteritis has witnessed a shift from symptomatic control (with oral rehydration therapy, anti-emetics, and H2 blockers) to a treatment focused on the pathophysiological approach of the disease, including a disruption of the GI environment. This pathogenic element of AGE, i.e., aberrant GI microbiota, could be explicitly addressed by probiotics. (6)
A study conducted in Western India found that Rotavirus A (30.5%), Norovirus (14.3%), Adenovirus (5.5%), and Astrovirus (5.5%) were the four gastrointestinal viruses that caused the majority (54%) of cases of acute gastroenteritis (AGE) in children under the age of two. (7) This is consistent with other South Asian countries with a high prevalence of childhood diarrheal infections; and 70% of cases of acute gastroenteritis in children where it is of viral origin. (8)
A recent meta-analysis evaluated the effectiveness of probiotics against a placebo or standard treatment for viral gastroenteritis. The results were promising and highlighted that probiotics could improve symptoms of viral gastroenteritis, including the duration of diarrhea and hospitalization. Such findings support the fact that probiotics can provide the supportive therapy needed in viral AGE and the rampant use and abuse of antibiotics, without diagnosing the exact underlying pathogens, needs to be re-analysed. (8)
Probiotics putatively interfere with viral replication at different levels by blocking viral attachment, synthesizing antiviral compounds, or inducing their synthesis by epithelial cells. Probiotics and epithelial/immune cell interaction improves innate and adaptive immune responses as well as barrier functioning. (9)
- Probiotics are living bacteria that thrive in the gastrointestinal system and, when consumed appropriately, provide health benefits to the host. Some probiotic strains are a safe treatment for acute infectious diarrhea, reducing the length and severity of the condition. (3)
- Probiotics have been found to have luminal functions, including antibacterial and metabolic activities, tight junction preservation, and regulation of the intestinal flora. Some probiotic strains have anti-inflammatory and trophic effects on the mucosa. (3)
- Probiotics may also affect the composition and function of microbial communities by competition for nutrients, production of growth substrates or inhibitors, and modulation of intestinal immunity. (8) Corroborating these, research reveals that probiotics decreased the length and frequency of acute diarrhea by 14.0%. (10)
Genus Lactobacilli in Managing AGE-
With the increased use of probiotics globally, the Lactobacilli genus has emerged as one of the most extensively studied and best-known probiotic strains. (3,6)
- The therapeutic advantages of Lactobacillus sporogenes are its capacity to generate antimicrobial substances, which prevent the growth of harmful bacteria and maintain healthy microbiota populations. (8)
- Research has documented that some L. sporogenes strains can release bacteriocin, a well-known antibacterial agent. These bacteriocins penetrate the surface of pathogenic bacteria and release amino acids and inorganic salts from the cells, thus inhibiting the growth of these bacteria. (8)
- Also, because of its ability to produce lactic acid, L. sporogenes can promote gut epithelial development and repair. (8)
- Against Acute rotavirus diarrhea- An Indian Experience: A placebo-controlled trial investigated the impact of L. sporogenes on the frequency and duration of acute rotavirus diarrhea. One hundred and twelve newborns were enrolled in the trial from rural India. They were randomly assigned to receive either a daily oral dose of L. sporogenes or a placebo over 12 months. The results revealed fewer instances of diarrhea (3.4 +/- 1.0 vs. 8.6 +/- 1.7 in the placebo group, p = 0.02) and fewer days of illness (13 +/- 3 days vs. 35 +/- 5 days in the placebo group, p = 0.02). (11)
- Against Acute Viral Diarrhea- A double-blind, randomised, placebo-controlled study evaluated the efficacy and safety of synbiotic L.sporogenes in lessening the frequency and duration of diarrhea induced by rotaviral infection. Eighty children between 3 months and three years were enrolled and divided into two groups, one group received standard therapy and placebo, and the other group received standard therapy and probiotics randomly. L.sporogenes showed clinical as well as statistically significant reduction in the number of episodes of diarrhea in a day, mean duration of diarrhea (in days), degree of dehydration, duration and volume of oral rehydration salt therapy, duration and volume of intravenous fluid therapy, duration of rotaviral shedding (P<0.01). The synbiotic L.sporogenes appears to be a safe and effective adjuvant in managing acute rotaviral diarrhea. (12)
- Against Acute Diarrhea- The effectiveness of L.sporogenes in treating acute diarrhea in children was examined in a randomised trial. In the 62 children (1 month to 6 years old) enrolled in the trial, one group received only fluids and zinc and another group L.sporogenes in addition to fluid and zinc. The L.sporogenes group displayed statistically significant reductions in diarrhea frequency on the second day of therapy, and improved stool consistency was noted on the same day. The study's results suggest that adding L.sporogenes to the treatment plan for diarrhea in the pediatric population results in a quicker improvement of symptoms in terms of stool frequency and consistency. (13)
Using Probiotics in Managing AGE – Review of Guideline Recommendations
A position paper by the ESPGHAN Working Group for Probiotics put forth the following recommendations for using probiotics for treating AGE in previously healthy infants and children. (2)
- Probiotics (as a group) as an adjunct to rehydration therapy reduced the duration of diarrhea by approximately one day. The Lactobacillus genus is among the highly recommended group of probiotics.
- Probiotic effects are strain-specific; thus, the efficacy and safety of each should be established, and recommendations for using these strains should be made accordingly.
- While choosing a probiotic, the efficacy should be confirmed in well-conducted RCTs and preferred by a manufacturer with regulated quality control of factors, including the composition and content of the probiotic agents.
Key Practice Pointers
- Acute gastroenteritis is a frequently encountered inflammatory disease with severe chronic sequels if not managed optimally in the acute phase.
- Probiotics act as therapeutic and preventative approaches to help the gut microbiome restore its physiological state. There is ample evidence highlighting that certain probiotic strains reduce the duration of acute diarrhea.
- Research documented that Lactobacilli strains have emerged as one of the AGE's most studied probiotic strains.
- The primary mechanism of L. sporogenes effectiveness in AGE is its targeted benefits on the gut microbiome, which are mediated by well-coordinated processes that favourably affect the host's microbiota, metabolism, and immune system.
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1. Castaño-Rodríguez, N., Underwood, A. P., Merif, J., Riordan, S. M., Rawlinson, W. D., Mitchell, H. M., & Kaakoush, N. O. (2018). Gut Microbiome Analysis Identifies Potential Etiological Factors in Acute Gastroenteritis. Infection and Immunity, 86(7). https://doi.org/10.1128/IAI.00060-18
2. Hemarajata P, Versalovic J. Effects of probiotics on gut microbiota: mechanisms of intestinal immunomodulation and neuromodulation. Therap Adv Gastroenterol. 2013;6(1):39-51. doi:10.1177/1756283X12459294
3. Vandenplas Y, Probiotics and prebiotics in infectious gastroenteritis, Best Practice & Research Clinical Gastroenterology (2016), doi: 10.1016/j.bpg.2015.12.002
4. Chow CM, Leung AK, Hon KL. Acute gastroenteritis: from guidelines to real life. Clin Exp Gastroenterol. 2010;3:97-112. doi:10.2147/ceg.s6554
5. Szajewska, Hania*; Guarino, Alfredo†; Hojsak, Iva‡; Indrio, Flavia§; Kolacek, Sanja‡; Shamir, Raanan||; Vandenplas, Yvan¶; Weizman, Zvi#. Use of Probiotics for Management of Acute Gastroenteritis: A Position Paper by the ESPGHAN Working Group for Probiotics and Prebiotics. Journal of Pediatric Gastroenterology and Nutrition: April 2014 - Volume 58 - Issue 4 - p 531-539 doi: 10.1097/MPG.0000000000000320
6. Kluijfhout, S., Trieu, V., & Vandenplas, Y. (2020). Efficacy of the Probiotic Probiotical Confirmed in Acute Gastroenteritis. Pediatric Gastroenterology, Hepatology & Nutrition, 23(5), 464-471. https://doi.org/10.5223/pghn.2020.23.5.464
7. Gopalkrishna V, Joshi MS, Chavan NA, et al. Prevalence and genetic diversity of gastroenteritis viruses in hospitalized children < 5 years of age in Maharashtra state, Western India, 2017-2019. J Med Virol. 2021;93(8):4805-4816. doi:10.1002/jmv.27085
8. Cao, J., Yu, Z., Liu, W., Zhao, J., Zhang, H., Zhai, Q., & Chen, W. (2020). Probiotic characteristics of Bacillus coagulans and associated implications for human health and diseases. Journal of Functional Foods, 64, 103643. https://doi.org/10.1016/j.jff.2019.103643
9. Rodríguez-Díaz J, Monedero V. Probiotics against Digestive Tract Viral Infections. Bioactive Food as Dietary Interventions for Liver and Gastrointestinal Disease. 2013;271-284. doi:10.1016/B978-0-12-397154-8.00031-2
10. Applegate JA, Fischer Walker CL, Ambikapathi R, Black RE. Systematic review of probiotics for the treatment of community-acquired acute diarrhea in children. BMC Public Health. 2013;13 Suppl 3(Suppl 3):S16. doi:10.1186/1471-2458-13-S3-S16
11. Chandra RK. Effect of Lactobacillus on the incidence and severity of acute rotavirus diarrhea in infants. A prospective, placebo-controlled double-blind study. Nutr Res 2002;22:65-69
12. Narayanappa D. Randomized double blinded controlled trial to evaluate the efficacy and safety of Bifilac in patients with acute viral diarrhea. Indian J Pediatr. 2008;75(7):709-713. doi:10.1007/s12098-008-0134-2
13. Manyal AK and Phadke VD: Role of Probiotic Lactobacillus Sporogenes in the Treatment of Acute Diarrhea in Children. Int J Pharm Sci Res 2015; 6(2): 767-71.doi: 10.13040/IJPSR.0975-8232.6 (2).767-71.
Dr Kamal Kant Kohli-MBBS, DTCD- a chest specialist with more than 30 years of practice and a flair for writing clinical articles, Dr Kamal Kant Kohli joined Medical Dialogues as a Chief Editor of Medical News. Besides writing articles, as an editor, he proofreads and verifies all the medical content published on Medical Dialogues including those coming from journals, studies,medical conferences,guidelines etc. Before Joining Medical Dialogues, he has served at important positions in the medical industry in India including as the Hony. Secretary of the Delhi Medical Association as well as the chairman of Anti-Quackery Committee in Delhi and worked with other Medical Councils in India. Email: email@example.com. Contact no. 011-43720751