Pre and Probiotic Use in Mixed Dysbiosis

Contraindications and Precautions

The American Gastroenterological Association recommends avoiding pre and probiotic intervention in critically compromised, immunosuppressed, or patients with damaged intestinal mucosa, as risks outweigh potential benefits 1, 2
Patients with immunosuppression, such as those with HIV and low CD4 count, chemotherapy, or immunosuppressive therapy, are at documented risk of bacteremia, fungemia, and sepsis from probiotics 2
Critically ill or severely debilitated patients have documented cases of sepsis induced by probiotics 1, 2
Patients with severe acute pancreatitis are at increased risk of mortality with multispecies preparations 1, 2
Central venous catheters pose a high risk of line-associated infections 2
Valvular heart disease increases the risk of endocarditis from bacteremia 2
Damaged intestinal mucosa or short bowel syndrome increases the risk of bacterial translocation 1, 2
Crohn's disease with stenosis has relative contraindications for prebiotic fibers due to the presence of stenosis, and fructo-oligosaccharides have shown no benefits 3, 4, 5, 6
Premature neonates have documented severe adverse events, including deaths from contaminated products 2

The European Society for Clinical Nutrition and Metabolism supports the use of probiotics, such as Lactobacillus, Bifidobacterium, Streptococcus, or Saccharomyces boulardii, for the prevention of antibiotic-associated diarrhea 3, 6
The American Gastroenterological Association recommends considering multispecies probiotics, such as VSL#3, for the prevention of pouchitis in ulcerative colitis post-colectomy 3, 6
The European Society for Clinical Nutrition and Metabolism suggests E. coli Nissle 1917 as an alternative to 5-ASA in mild-moderate ulcerative colitis when not tolerated 6

Start with natural prebiotic foods, such as fruits, garlic, onions, bananas, and asparagus, before considering concentrated supplements 5, 6
A Mediterranean diet is associated with higher ratios of bifidobacteria to E. coli 5
Initial bloating and flatulence are common during fermentation 5, 6
If proceeding with probiotics, select well-studied, specific strains, such as Bifidobacterium infantis, at a dose of 1×10⁸ CFU/day for at least 4 weeks 5, 6
Lactobacillus rhamnosus GG or Saccharomyces boulardii may be considered for specific conditions 2
Identification at the species and strain level, with a minimum effective dose of 10⁸ CFU/day, is essential 6

The probiotic market suffers from inadequate regulation, posing serious risks, especially when used for medical conditions 2
Products may contain contaminants or lack declared bacterial strains 1, 2
Laws on branding allow manufacturers to market different formulations under the same name, even if significantly different from the originally tested product 2
The "probiotic umbrella concept" allows for inappropriate extension of claims from a tested strain to untested formulations 2
Choose products with strains deposited at ATCC or similar certifications to verify quality 2

The effectiveness of probiotics is highly strain-specific, and results from one probiotic cannot be generalized to all probiotics 6, 2
Lactobacillus plantarum alone or in combination is associated with a significant reduction in overall infections in critically ill patients, possibly due to its ability to prevent pathogen adhesion 7
Probiotics alone have shown a greater effect than synbiotics on infections, although the difference is not significant 7

Patients on warfarin should increase INR monitoring when starting probiotics, although clinically significant interactions are rare 2
Common minor side effects include abdominal cramps, bloating, and pain in healthy individuals, although severe events are rare 2
Saccharomyces boulardii requires particular caution due to its association with fungemia in critically ill and immunocompromised patients 1, 2