Comment on: Probiotics and Antibiotic-Related Effects on the Microbiome – do they help? Review by Mr. Cass Condray (USA). News You Can Use, World Gastroenterology Organisation.

Hania Szajewska¹, Karen Scott², Daniel Tancredi³, Marla Cunningham⁴, Mary Ellen Sanders⁵.

1. Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland.
2. Rowett Institute, University of Aberdeen, Aberdeen, UK.
3. Department of Pediatrics, University of California at Davis, Sacramento, CA, USA.
4. International Scientific Association for Probiotics and Prebiotics, Brisbane, Australia
5. Mary Ellen Sanders LLC, Centennial, CO, USA.

Prof. Eamonn Quigley
Editor in Chief
News You Can Use, World Gastroenterology Organisation

Dear Prof. Quigley,

We thank Mr. Cass Condray for reviewing our recent article as a commentary in the World Gastroenterology Organisation (WGO) News You Can Use platform. The commentary highlights some important features of this article and associated literature. However, we wish to clarify certain conclusions in the WGO commentary with regard to the clinical impact of probiotics on antibiotic-associated diarrhoea (AAD) and Clostridioides difficile-associated diarrhoea (CDAD). These conclusions do not reflect the content of our article, which was careful to distinguish between evidence for clinical impact and evidence for a specific hypothesised mechanism by which those impacts could be achieved.

In Szajewska et. al¹ the primary focus was on a hypothesised mechanism, addressing the question of whether probiotics can help restore an antibiotic-disrupted gut microbiota. The evidence, as we noted, is insufficient to conclude restoration of the microbiota to a pre-antibiotic state, although some specific probiotics may attenuate features of microbiome disruption. However, we also noted that there is evidence for beneficial clinical impacts of probiotics, contrary to the conclusion of the WGO commentary.

Clinical evidence is surely relevant in the absence of a delineated mechanism. Our article cites evidence for the impact of specific probiotics on the clinical endpoints of prevention of AAD and CDAD. Such evidence is supported by many meta-analyses of existing data and has been recognised by several clinical organisations, including the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (AAD² and CDAD³), World Gastroenterology Organisation (AAD and CDAD⁴), and American Gastroenterology Association (CDAD⁵). Unfortunately, the meta-analyses we cite that show a reduction in diarrhoea duration do not usually measure microbiota composition. As a result, any impacts on microbiota restoration could not be assessed.

We consider that both of these important points are true: evidence that probiotics can restore an antibiotic-perturbed gut microbiota is lacking AND evidence that probiotics can prevent CDAD and AAD is clinically relevant and available.  In our review, we state “In conclusion, evidence from several meta-analyses has consistently shown that certain probiotics reduce the risk of AAD or CDAD. However, there is no conclusive evidence to support a general statement that probiotics prevent antibiotic-induced shifts in community structure and complexity (α-diversity and β-diversity) and there is limited evidence that probiotics interfere in post-antibiotic microbiome recovery.” An important avenue for future research is study of the mechanism(s) through which probiotic bacteria can provide these clinical benefits, and whether they are linked to microbiota recovery.

Misunderstandings about probiotics and antibiotics are common among clinicians. For this reason, we wish to clarify that our paper, contrary to Mr. Condray’s commentary, acknowledges their clinical benefits. Our aim is to ensure clear and accurate communication of the current evidence base. We appreciate the opportunity to provide comment and thank you for your consideration of this letter.

References

1. Szajewska H, et al. Antibiotic-perturbed microbiota and the role of probiotics. Nat Rev Gastroenterol Hepatol. 2025 Mar;22(3):155-172. doi: 10.1038/s41575-024-01023-x
2. Szajewska H, et al. Probiotics for the Management of Pediatric Gastrointestinal Disorders: Position Paper of the ESPGHAN Special Interest Group on Gut Microbiota and Modifications. J Pediatr Gastroenterol Nutr. 2023 Feb 1;76(2):232-247. doi: 10.1097/MPG.0000000000003633.
3. Szajewska H, et al. Probiotics for the Prevention of Antibiotic-Associated Diarrhea in Children. J Pediatr Gastroenterol Nutr. 2016 Mar;62(3):495-506. doi: 10.1097/MPG.0000000000001081.
4. Guarner F, et al. World Gastroenterology Organisation Global Guidelines: Probiotics and Prebiotics. J Clin Gastroenterol. 2024 Jul 1;58(6):533-553. doi: 10.1097/MCG.0000000000002002.
5. Su GL, et al. AGA Clinical Practice Guidelines on the Role of Probiotics in the Management of Gastrointestinal Disorders. Gastroenterology. 2020 Aug;159(2):697-705. doi: 10.1053/j.gastro.2020.05.059.

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