Dr Colleen R. Kelly on the Lack of Evidence to Support Probiotics for C difficile 

Clinicians are finding that there really is no basis to recommend probiotics for patients with Clostridioides difficile infection, that instead they may cause harm, said Colleen R. Kelly, MD, FACG, gastroenterologist and associate professor of medicine at The Warren Alpert Medical School of Brown University.

Based on evidence from recent studies and other data, there really is no basis to recommend probiotics for individuals with Clostridioides difficile infection, said Colleen R. Kelly, MD, FACG, gastroenterologist with Lifespan Physician Group Gastroenterology practice and at the Center for Women’s Gastrointestinal Medicine and associate professor of medicine at The Warren Alpert Medical School of Brown University, speaking about updated guidelines from the American College of Gastroenterology.

Transcript

What do clinicians and patients need to know about the updated guidelines for Clostridioides difficile infection that discuss probiotics?

Probiotics have been this thing that a lot of us to treat who treat a lot of C diff see people spending a lot of money on, and they kind of have, in our mind, been a lot of magical thinking. We do this without a lot of data. We tell patients we know C diff is because you have too many bad bacteria and not enough good bacteria, so let's go to the store and buy these pills with good bacteria. Anything we recommend to patients, I just want to make sure we're not snake oil salesmen, that we're telling them to go buy something that's going to work. And I think with probiotics, I would see patients who came to me after having 3, 4, or 5 recurrent C diff infections with a bag of probiotics they're spending $100 or more a month on.

We took a real deep dive into the research to see if probiotics are effective at preventing C diff in the first place. So if you get a course of antibiotics for dental infection, or a UTI [urinary tract infection], should you take probiotics along with them to keep yourself from getting C diff, or after you already have C diff, if you take probiotics along with the C diff treatment or afterwards, is your C diff less likely to come back again—so secondary prevention—and we really found that probiotics didn't appear to be effective in either of those situations. There are a few studies here and there, but most of the better done studies, the prospective randomized controlled trials of probiotics for primary prevention, have been negative studies and not shown any benefit over placebo, and the few smaller studies that have were a little suspect in terms of methodologies and sample sizes. They had really high rates of C diff in their background, placebo-treated populations that really exceeded anything that we see here. And so there really just wasn't anything compelling to show that they helped.

Some people will say, “Well, even if they don't really help, maybe they don't hurt and maybe they make the patient feel proactive, like they're doing something for themselves. I think we're actually finding, they may hurt. There's been a couple of studies that have shown that probiotics may actually be detrimental to normal recolonization of the gut, that the gut flora after a course of antibiotics, [probiotics] may disrupt that normal balance. Also patients who are immunocompromised, there have been reports of probiotics bacteremia or fungemia, particularly in people who are hospitalized. And I have seen people in the hospital who are really sick getting probiotics, and that's certainly a situation where we wouldn't want people getting them.

So there's not enough data for benefit, and now there's kind of some data that it could be harmful. There’s really no reason we should, as doctors, and based on the current science, be recommending this to patients.