Role of Probiotics in Gastroenteritis

Introduction to Probiotic Use

The American Gastroenterological Association recommends against using probiotics for acute infectious gastroenteritis in children in the United States and Canada, based on two large, high-quality multicenter trials showing no benefit 1, 2
The evidence for probiotics in gastroenteritis is highly geography-dependent, creating a clinical paradox 1, 2

The American Gastroenterological Association recommends against using probiotics for acute gastroenteritis in children in North America, as two rigorous multicenter trials (943 and 827 children) showed no benefit for either L. rhamnosus ATCC 53103 or the combination of L. rhamnosus R0011 with L. helveticus R0052 1, 2, 4, 5, 6
Neither L. rhamnosus ATCC 53103 nor the combination of L. rhamnosus R0011 with L. helveticus R0052 reduced moderate-to-severe gastroenteritis (Vesikari scale ≥9) compared to placebo in North American children 4, 6
Outside North America, probiotics may reduce diarrhea duration by approximately 22 hours (95% CI: 16.17-27.64 hours), though evidence quality is low 2, 4
The European Society for Paediatric Gastroenterology recommends L. reuteri DSM 17938 as adjunct treatment in children outside North America 3

Saccharomyces boulardii may reduce diarrhea duration by 28.9 hours (95% CI: 16.78-41.03 hours), but evidence quality is very low 2, 3, 4
Lactobacillus rhamnosus GG (ATCC 53103) may reduce diarrhea duration by 23.13 hours (95% CI: 12.33-33.94 hours), low certainty 2, 3, 4
Lactobacillus reuteri may reduce diarrhea duration by 24.36 hours (95% CI: 33.55-13.17 hours), low certainty 3, 4

The American Gastroenterological Association recommends using L. rhamnosus GG or S. boulardii to prevent antibiotic-associated diarrhea, which reduces risk by approximately 50%, moderate-quality evidence 3
Probiotics reduce Clostridioides difficile infection risk by 64% when given with antibiotics, moderate certainty 3
Combination probiotics (Lactobacillus + Bifidobacterium species) may be used in preterm infants <37 weeks gestational age to prevent necrotizing enterocolitis, moderate-to-high quality evidence 1, 2, 3

If in US/Canada, do not use probiotics for acute gastroenteritis 1, 2, 3
If outside North America, consider probiotics as adjunct to rehydration, with S. boulardii as first choice, and L. rhamnosus GG or L. reuteri DSM 17938 as alternatives 2, 3, 4

Avoid probiotics in high-risk populations, including immunocompromised patients, premature neonates, patients with central venous catheters, critically ill patients, cardiac valvular disease, and short-gut syndrome 1, 3