How to choose probiotics to prevent antibiotic-related diarrhea?

*The professional part involved in this article is only for medical professionals to read for reference.
For antibiotic-related diarrhea, the higher level of recommendation is in the clinical work of Saccharomyces boulardii.
We will find that about 5% of children using antibiotics -39% of children have diarrhea, and even diarrhea occurs within 2 weeks of stopping antibiotics.
Now, in combination with the latest guidelines and clinical cases, I will discuss with you: to prevent antibiotic-related diarrhea, how to choose probiotics? Child XX; male; November, 1 week of cough, 2 days of fever, came to see the clinic, 1 week ago, there was no obvious cause of cough, mainly dry cough, with runny nose, no fever, oral "azithromycin, lung cough" treatment 3 Day, the effect was not good, fever occurred 2 days after admission, the highest body temperature was 40°C, and chills appeared, accompanied by perioral bruising, no diarrhea, come again, physical examination: T39.
2°C, P156 times/min, R 42 times/ Points, BP101/67mmHg, SPO298% (low-flow oxygen inhalation), weight 9kg, mentally tired, slightly short of breath, coarse breath sounds in both lungs, and fine wet rales can be heard
.

Admission to the hospital for complete inspection: blood routine: WBC 24.
9×109/L, NE 73.
85%, HGB 119g/L, RBC 4.
53×1012/L, PLT 337×109/L; CRP 131mg/L
.

Chest radiograph showed bronchopneumonia
.

To keep the respiratory tract unobstructed, ceftriaxone anti-infection (100mg/kg), globulin to regulate immunity, antipyretic, fluid replacement and other symptomatic and supportive treatment
.

On the fourth day of treatment, the peak fever of the child decreased, and the blood inflammation index after rechecking decreased, but the number of stools increased to 4 times/day.
There was no loose stools, no mucus and bloodshots, no vomiting, and no obvious abnormalities in stool routine.
Add cloth Rachian yeast 250 mg qd orally, the child improved and discharged on the eighth day of treatment, and his stool returned to normal
.

Discharge diagnosis: bronchopneumonia; antibiotic-related diarrhea
.

  What is antibiotic-related diarrhea? Diarrhea that cannot be explained by other reasons after antibiotic treatment, the number of stools> 2 times a day, for more than 2 days, and other reasons are excluded, consider antibiotic-related diarrhea, which is the most common adverse reaction after the use of antibiotics
.

 The pathogenesis of antibiotic-associated diarrhea is complex and mainly involves the following four aspects: 1.
Intestinal flora imbalance.
Microorganisms in the human intestine restrict each other to play the necessary physiological functions for the human body to defend against infection, maintain barriers, immunity, metabolism, and nutrition.
However, while antibiotics have a therapeutic effect on diseases, they also inhibit sensitive microorganisms in the intestinal tract
.
The excessive proliferation of non-sensitive flora leads to imbalance of intestinal flora and diarrhea .

 2 Conditional pathogens infect the intestinal flora imbalance, so that conditional pathogens such as Clostridium difficile, Staphylococcus aureus, Klebsiella oxytoca, Candida albicans and other conditional pathogens can directly cause disease.
Special attention should be paid to: 10%-33% of antibiotic-related diarrhea is caused by Clostridium difficile infection
.

 3 The metabolism of carbohydrates and bile acids in the intestine is reduced.
Antibiotics reduce the fermentation of carbohydrates in the colon by antibiotics.
Unfermented sugars, excess water and sodium can cause osmotic diarrhea; on the other hand, antibiotics can cause dehydroxylation.
The number of flora decreases and the concentration of primary bile acids increases, which promotes colonic secretion and causes secretory diarrhea
.

 4 Certain antibiotics directly stimulate the intestinal motility, such as erythromycin, amoxicillin and clavulanate potassium and other antibiotics.
They can directly stimulate the increase in intestinal motility and cause diarrhea
.

If the child has recently used or is taking antibiotics and has loose stools or watery stools, even mucus stools, pus-blood stools, bloody stools, flakes or tubular pseudomembranes, and can not be explained by various clear causes, it can be Clinical diagnosis: antibiotic-related diarrhea
.

 Treatment: including discontinuation or adjustment of antibiotics, the application of probiotics, the treatment of special pathogens in AAD, fecal bacteria transplantation and symptomatic supportive treatment
.

Here, we only discuss the application of probiotics
.

  Antibiotic-related diarrhea, how to choose probiotics? Intestinal flora imbalance is the main pathogenesis of antibiotic-associated diarrhea.
Therefore, theoretically returning to normal intestinal flora will have a therapeutic effect on the disease.
However, the current clinical data on the use of probiotics is extremely limited
.

 Let’s look at the picture below.
This is a recommendation given by various authoritative indicators or organizations.
For antibiotic-related diarrhea, Saccharomyces boulardii is recommended at a higher level, which is why we chose this case
.

  In addition to Saccharomyces boulardii, the Probiotics and Prebiotics Working Group of the European Pediatric Gastroenterology, Hepatology and Nutrition Society recommends the use of Lactobacillus rhamnosus GG for the use of probiotics to prevent antibiotic-related diarrhea in children
.

 So, what is the safety and effectiveness of Saccharomyces boulardii for infants and young children? A study published by Wan Chaomin and others in the Chinese Journal of Pediatrics showed that 408 cases of children between January and 3 years of age were treated with antibiotics and 250 mg of Saccharomyces boulardii per day was added, which was compared with those without probiotics.
In terms of children, the addition of Saccharomyces boulardii can effectively reduce the incidence of antibiotic-related diarrhea by 18.
9%, and within 2 weeks of stopping the drug, Saccharomyces boulardii can also effectively reduce the recurrence of antibiotic-related diarrhea.
With a rate of 14% and no adverse reactions, it can be used as one of the drugs of choice for the prevention of antibiotic-related diarrhea in infants and young children
.

 Probiotics of other bacteria, what are the advantages or disadvantages of Saccharomyces boulardii in the prevention and treatment of antibiotic-related diarrhea? First, fungi are not afraid of antibiotics, while bacteria are sensitive to certain antibiotics
.

What is the proof, let’s take a look at this study: This is a foreign study, under in vitro conditions, the common probiotics against commonly used antibiotics (penicillins, cephalosporins, macrolides, quinolones, fidaxomycin ) Sensitivity
.

  The results of the study are shown in the figure below.
The red area represents that the probiotics are sensitive to the antibiotic, while the white area is insensitive to the antibiotics.
It can be seen that the fungal probiotics are not sensitive to the antibiotics selected this time, which is consistent with common sense.
Probiotics have different degrees of sensitivity to antibiotics.
Therefore, when choosing probiotics and antibiotics to prevent antibiotic-related diarrhea, you need to ensure that the probiotic strains used are not sensitive to antibiotics.
However, under the condition of the body, probiotics, Whether it is also consistent with this experiment is unknown, and further research is needed
.

  Having said so much, everyone will probably ask, when is the time to prevent antibiotic-related diarrhea? When there are the following situations, probiotics can be added to the prescription of antibiotics, and the choice of probiotics, the benevolent sees the benevolent, the wise sees wisdom: 1.
Broad-spectrum antibiotics (β-lactams, macrolides, quinolones) and anti-anaerobic bacteria Antibiotics 2.
Antibiotics (erythromycin, clindamycin, cefoperazone) that are metabolized by the liver or excreted in the bile.
3.
Antibiotics are expected to be treated for more than 8 days.
4.
Antibiotics are used in combination.
5.
Other conditions: premature delivery.
children, low birth weight children aged <3 years old, intestinal invasive procedures, have antibiotic-associated diarrhea and so on
.

  References: 1.
Szajewska H, ​​Kolodziej M [J].
Aliment Pharmacol Ther, 2015, 42(7): 793-801.
2.
Zheng Yuejie, etc.
, Expert consensus on diagnosis, treatment and prevention of antibiotic-related diarrhea in children, Chinese Journal of Practical Pediatrics , 2021, 36(6): 424-4303.
World Gastroenterology Organisation.
Probiotics and prebiotics, World Gastroenterology Organisation Global Guidelines.
2017.
4.
Cruchet S.
Pediatr Drugs 2015;17:199-2165.
Application of probiotics in children with gastrointestinal diseases in the Asia-Pacific region Recommendation 2017 6.
Clinical practice guidelines for acute infectious diarrhea in children in China 20167.
Evidence-based guidelines for the clinical application of probiotics in pediatrics 2017.
038.
Szajewska et al.
J Pediatr Gastroenterol Nutr.
2016;62:495-5069.
Wan Chaomin, Fang Feng et al.
.
Chinese Journal of Pediatrics.
2017.
55(5):349-354.