R E V I E W A R T I C L E

Probiotics in Health and DiseaseS Anuradha*, K Rajeshwari**

* Assistant Professor, Department of Medicine, ** Associate Professor, Department of Paediatrics,Maulana Azad Medical College, New Delhi - 110 002.

Probiotics have been with us for as long as people haveeaten fermented milk, but their association with healthbenefits dates only from the turn of the last century,when Metchnikoff drew attention to the adverseeffects of some gut microflora on the host, andsuggested that ingestion of fermented milkameliorated this so-called auto-intoxication. In 1965,Lilley and Stillwell used the term ‘probiotic’ to describethem as beneficial micro-organisms1. Finally, in 1989Fuller defined them as ‘A live microbial foodsupplement which beneficially affects the host animalby improving its microbial balance2.

What is the need for probiotics?The vast majority (> 90%) of the total cells in the bodyare present as bacteria in the colon, reaching 1012 forevery gram of large intestinal contents. Under naturalconditions, a protective gut microflora develops andthere is no need for a bacterial supplement. But thechanging food habits and lifestyle force us to takeprocessed and sterile food, which affects our accessto, and colonisation, by certain type of bacteria.Moreover, we also consume antibacterial substancesranging from vinegar to antibiotics.

Potential of ‘everyday standard’ food itemsto promote healthy GI microfloraSome standard food items, e.g., yogurt, sauerkraut,garlic, and cheese contain probiotics in the form of livelactic acid bacteria and/or probiotics in the form offructans, a dietary fibre3. Cheese contains bothprobiotic bacteria and the prebiotic dietary fibre inulin.The regular consumption of cheese has beenassociated with a reduct ion in the r isk ofCampylobacter enteritis.

Further, cheese is known to contain compounds thatreduce the risk of dental caries. In a study by Ahola etal, results from logistic regression showed that short-

term consumption of cheese containing LactobacillusGG and Lactobacillus rhamnosus LC 705 showed a trendindicating that probiotic intervention might reduce therisk of the highest levels of Streptococcus mutants andsalivary yeasts4.

Currently used probioticsThe majority of probiotics are bacteria with the speciesof lactobacillus and bifidobacterium being the mostcommon type of bacteria used. Table I shows the listof micro-organisms used as probiotics.

Table I : Micro-organisms used as probiotics.

A. Bacteria

i. Lactobacillus: acidophilus, sporogenes, plantarum,rhamnosum, delbrueck, reuteri, fermentum, lactus,cellobiosus, brevis

ii. Bifidobacterium: bifidum, infantis, longum,thermophilum, animalis

iii. Streptococcus: lactis, cremoris, alivarius, intermedius

iv. Leuconostoc

v. Pediococcus

vi. Propionibacterium

vii. Bacillus

viii. Enterococcus

ix. E. faecium

B. Yeast and mouldsA. cerevisiae, A. niger, A. oryzue, C. Pintolopesii,Sacharomyces boulardii.

A bacteria, before being selected as a probiotic, shouldbe non-pathogenic, non-toxigenic, should retainviability during storage and use, should have thecapacity to survive and metabolise in the gut, andfinally should have documented health effects. L.rhamnosus strain GG meets most of these criteria.

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Table II : Indications for probiotics5.

Proven indications– Rotavirus diarrhoea

– Reduction of antibiotic-associated side effects

Possible indications– Food allergies and lactose intolerance

– Atopic eczema

– Prevention of vaginitis

– Urogenital infections

– Irritable bowel syndrome

– Inflammatory bowel disease

– Cystic fibrosis

– Traveller’s diarrhoea

– Dental caries

– Enhance oral vaccine administration

– H. pylori infection

– Various cancers

Protective effects of probioticsProbiotics generally enhance the intestinal microflora byreplenishing suppressed bacteria and inhibiting thegrowth of more pathogenic flora6. Some probioticsincluding Lactobacillus GG actively secrete anantimicrobial substance which inhibits the growth ofcertain other organisms7. Volatile fatty acids produced bythe indigenous microflora, of which lactic acid bacteriaform a part, are responsible for controlling the colonisationof gut by S. Sonnei and Enteropathogenic E. coli. Probioticslike S. faecalis, C. butyricum and B. mesentericus growprofusely and also accelerate the growth ofbifidobacterium8,9. Bifidobacterium is not only anantagonist of pathogenic organisms, but it also producesglutamine from NH4

+ and glutamic acid. Glutamine is wellknown as a major supplement for intestinal epitheliumand maintains mucosal integrity. Additionally, metabolitesof these three bacteria, butyrate, and acetate, create aharmful environment for pathogenic E. coli, Salmonellaand methicillin resistant S.-aureus, by lowering intestinalpH8. Butyrate is also required by intestinal epithelial cellsas a supplement to stimulate proliferation of normalepithelium and plays a role in maintaining mucosal barrierdefenses.

Probiotics in DiarrhoeaSaavedra et al showed that supplementation of infant milkformula with B. bifidum and S. thermophilus reducedrotavirus shedding and episodes of diarrhoea in childrenin hospital10. In a study of HIV associated acute diarrhoea,Saint Marc reported that 56% of patients who were treatedwith S. boulardii had their symptoms resolved comparedwith only 6% of placebo treated patients11. Gorbach et aldemonstrated that Lactobacillus GG successfullyeradicated C. difficile in five patients with relapsing colitis,when they were fed viable lactobacilli in skimmed milkdaily12. Further reduction in incidence of traveller’sdiarrhoea has been reported by many studies13,14.

These studies demonstrate that a probiotic can beeffective in treating antibiotic induced diarrhoea,diarrhoeal disease acquired during travel, which mostlikely has a mixed bacterial and viral etiology, anddiarrhoeal diseases in young children caused by rotavirus.

Probiotics in lactose intoleranceKim and Gilliland found that feeding fermented milk tolactose intolerant subjects resulted in a significantly lowerlevel of hydrogen in the breath when compared to thehydrogen level for subjects fed unfermented milk15.Hydrogen in the breath is a marker for bacterialmetabolism of lactose in the large bowel. A lowerhydrogen level indicates that lactose has beenmetabolised prior to entering the large intestine.

Antimutagenic and anticarcinogenicproperties of probioticsProbiotics can be antimutagenic in several ways. Theenteropathogens such as E. coli and Clostridiumperfringens produce enzymes such as beta-glucuronidase,and nitroreductase. Beta-glucosidase and urease canconvert procarcinogens to proximate carcinogens16. Thecolonising cells of bifidobacterium produce lactic acid andlower the intestinal pH and create a bactericidalenvironment for these putative enteropathogens, andthus develop a favourable microenvironment whichmodulates the bacterial enzymes. Purified bifidobacterialhas cell wall antitumour activities and induces activationof phagocytes to destroy growing tumour cells17. RASactivation represents one of the earliest and most

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frequently occurring genetic alterations associated withhuman cancers, especially carcinoma of colon. Elevatedlevels of ras P-21 have been correlated with increased cellproliferations, histologic grade, nuclear aplasia and degreeof undifferentiation18.

Reddy et al demonstrated that dietary B. longum culturessignificantly suppressed the expression of total andneonated ras P-21 in the colonic mucosa and tumourscompared with control diet19.

An additional mechanism of tumour suppression mayinvolve a role for B. Longum as an immunomodulator andbiological response modifier20. Probiotics also stimulateapoptosis through end-product formation.

Probiotics and immune enhancementThe colonic microflora affects mucosal and systemicimmunity in the host. Intestinal epithelial cells, bloodleucocytes, B and T lymphocytes, and accessory cells ofthe immune system are all complicated targets forprobiotics21. The effect is produced either by absorptionof a soluble antigen or by translocation of ‘lactobacilli’through the gut wall into the blood stream22. Lactobacilliwhich adhere to human intestinal epithelial cells arecapable of activating macrophages23.

Probiotics and irritable bowel syndrome (IBS)There have been few studies involving probiotics and IBS.This may be because IBS is a multifactorial conditionmaking it difficult to study homogenous groups ofpatients. Halpern et al conducted a randomised doubleblind cross-over trial using Lacteol Fort®, an antidiarrhoealdrug containing 5x1010 heat killed organisms/capsule ofLactobacllus acidophilus or a placebo24. Theydemonstrated a statistically significant difference inoverall GI function, defined by clinical criteria, in theLacteol group in comparison to those receiving placebo.Hunter et al administered 1010 cfu/d of Enterococcusfaecium PR88 to twenty eight patients with high volumediarrhoea caused by food intolerance for twelve weeks25.There was a symptomatic improvement in nineteen of thetwenty eight patients, and a significant decrease in faecalweight. Several trials of probiotics in IBS have usedLactobacillus plantarum 299v as the main probiotic

organism with varying results26,27. The role of Lactobacilluscasei strain GG (LGG) in IBS was studied in a randomiseddouble blind cross-over trial28. The authors concluded thatLGG alone did not have an effect on symptoms of IBS.

The evidence of the use of probiotic bacteria in IBS is sofar inconclusive. The trials that have been performed havecentred on a symptomatic reduction or cure and haveproduced varying results. Currently, no organism can beconfidently recommended to patients as being likely tohelp their symptoms. However, the abnormalities seen incolonic flora of IBS suggest that a probiotic approach willultimately be justified.

Food allergy and probioticsLoskutova et al and Trapp et al in two different studiesreported that administration of probiotics was associatedwith disappearance of food allergy manifestation withdecrease in concentration of IgE in the serum and with alower frequency of allergies29,30. Probiotics, by theirpotentiating effect on the non-immunologic andimmunologic defense barrier of the gut, alleviate theinflammatory response in food allergy. Bifidobacteria andlactobacilli have been shown to enhance IgA productionin Peyer’s patches, and potentiate IgA response topotentially harmful antigens31. Probiotics reduce thesecretion of Th2 cytokines which are IL-4, IL-5, IL-6, IL-9, IL-10 and IL-13. These cytokines are responsible for strongantibody (esp IgG and IgE) responses and eosinophilafound in helminthic infections and allergic disorders.Probiotics induce the secretion of IL-12 by activatedmacrophages. IL-12 increases resistance to intracellularbacteriae and parasites. Lactobacilli modify theimmunomodulatory properties of native food protein32.Thus, probiotics influence the immune system byactivating the lymphoid cells of the gastrointestinallymphoid tissue.

Atopic dermatitis and probioticsStudies have been conducted to assess the role ofprobiotics in atopic disease. A study was conducted byKirjavainen PV et al to assess the efficacy of oralsupplementation of viable and heat inactivated probioticbacteria in the management of atopic disease33. The studypopulation included 35 infants with atopic eczema and

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allergy to cow’s milk. At a mean age of 5.5 months, theywere assigned in a randomised double blind manner toreceive either extensively hydrolysed whey formula(placebo group) or the same formula supplemented withviable Lactobacillus GG (viable LGG group) or heatinactivated Lactobacillus GG (heat inactivated LGG group)respectively. Within the study population, atopic eczemaand subjective symptoms were significantly alleviated inall the groups. It was concluded that supplementation ofinfant formulae with viable but not heat inactivated LGGis a potential approach for the management of atopiceczema and cow milk allergy.

Probiotics and vaccine adjuvantsIsolauri et al noted an increase in rotavirus specific IgMsecreting cells when the children were given LactobacillusGG as an adjuvant to an oral vaccine to rotavirus comparedto placebo on 8th post-vaccination day34. LGG alsoincreased IgA and IgM seroconversion when measuredin paired sera measured prior to vaccination, and after 30days of vaccination.

Probiotics in vaginitis and other urogenitalinfectionsAlthough antimicrobial therapy is generally effective ineradicating urogenital infections, there is still a highincidence of recurrence. There is good clinical evidenceto show that the intestinal and urogenital microbial florahave a central role in maintaining both the health and well-being of humans.

Bacterial vaginosisEssentially, bacterial vaginosis is considered as anovergrowth of anaerobic organisms combined with a lossof the protective lactobacilli normally found in the healthyvagina35. Recently, daily oral intake of probiotic strainsLactobacillus rhamnosus GR-I and Lactobacillus fermentumRC-14, resulted in asymptomatic bacterial vaginosispatients reverting to normal lactobacilli dominatedvaginal microflora36,37. The mode of action mightcompromise increased ascension of probiotic and/orindigenous lactobacilli from the rectal skin to the vaginaand enhancement of the intestinal mucosal immunitywhich effects vaginal immunity rendering the

environment less receptive to bacterial vaginosisorganisms.

Urinary tract infectionsThe basis for use of probiotics emerged from clinicalobservations in 1973, where a study of healthy womenshowed an association between lactobacilli presence inthe vagina and no history of UTI38. Extensive studies ofvarious lactobacilli strains led to the selection of a two-strain combination for vaginal use. This comprises distalurethral isolate L rhamnosus GR-1, selected primarily forits anti gram-negative activities and resistance tospermicide and L fermentum B-54 replaced more recentlyby RC-14, for anti gram-positive cocci activities andhydrogen peroxide production. In order to optimise aconsistent dose with a good shelf life in a formulationpreferred by patients, the organisms are freeze dried andplaced in gelatin capsules with dosage at 109 per capsulehigher than the total microbial content of the vagina39.Results from various studies indicate that the recurrencerate of UTI can be significantly reduced using one or twocapsules vaginally per week for a year with no side effectsor yeast infections39.

Blood lipids and probioticsSince the early work of Mann and Spoerry, probiotics havebeen reported to have cholesterol lowering properties inhumans. The proposed mechanism is that probiotics causedirect assimilation of lipids, convert them into othermetabolites and end products, which affects synthesis ofcholesterol40. Many studies have been conducted sincethen to prove this fact but because of many limitationsand confounding factors, none of the studies hadsufficient statistical power to detect changes in cholesterolof < 15%. It is clear that if probiotics do have a cholesterollowering effect, it is a relatively weak one compared withthe effect of powerful cholesterol lowering drugs.

Inflammatory bowel diseasesThe luminal bacterial flora and immunological responsesplay a major role in initiation and perpetuation of chronicinflammatory bowel disease. Probiotics by theirimmunomodulatory and bowel flora manipulatingproperties, show a promising effect in treatment of chronic

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inflammatory bowel disease41. More clinical trials areneeded to evaluate the true place of probiotics within atreatment regimen for chronic inflammatory boweldisease.

Side effects and safety profile of probioticsCases of infection due to lactobacilli and bifidobacteriumare extremely rare and are estimated to represent 0.05 -0.4% of cases of infective endocarditis andbacteraemia42,43. Of interest, increasing consumption ofprobiotic lactobacilli and bifidobacteria has not led to anincrease in such opportunistic infections in consumers.Immunocompromised patients generally are morevulnerable to infection with pathogens and have a higherincidence of opportunistic infections. However, there isno published evidence that consumption of a probioticthat contains lactobacilli or bifidobacteria increases therisk of opportunistic infection among such individuals. Inaddition, 2 clinical studies have been conducted to assessthe safety of probiotics in small groups of specificimmunocompromised patients (e.g., patients with HIVinfection), and the findings of these studies support thesafety of probiotics consumed by such groups44,45. Thereis no evidence that ingested probiotic lactobacilli orbifidobacteria pose any risk of infection greater than thatassociated with commensal strains. In quantitative terms,the existing data suggests that the risk of bacteraemiawhich is the most commonly reported of these infectionsis < 1 case per million individuals. It is virtually impossibleto propose a risk of death because of the commonassociation of infections involving lactobacilli with fatalunderlying conditions or the presence of polymicrobialinfections46. Vigilance regarding the detection of possiblerare cases of infections due to probiotics should bemaintained and isolates should be sent to referencecentres for molecular characterisation and confirmation.

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List of Prime-Reviewers of JIACM(January - December 2004)

JR Sankaran (Chennai)SH Talib (Aurangabad)Rita Sood (New Delhi)Rohini Handa (New Delhi)RSK Sinha (New Delhi)RK Garg (Lucknow)Rajesh Rajput (Rohtak)

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