PRE‐, PROBIOTICS AND SYNBIOTICS IN INFECTIOUS DIARRHEA
Authors: Dinleyici E. Cagri 
Published: July 2016

Acute diarrhea continues to be a leading cause of morbidity, hospitalisation and mortality worldwide and also resulting huge economical burden. The main method of therapy for all children with dehydration caused by diarrhoea is oral rehydration solution. Water and electrolyte replacement does not substantially shorten the frequency/duration of diarrhoea and has not been found to reduce stool volume, prompting a growing interest in adjunctive treatments. Probiotics have been proposed as a complementary therapy in the treatment of acute diarrhea. The most widely evaluated outcomes are the duration and severity of diarrhoea, and the duration of hospitalisation. There have been many randomised, controlled studies and observational studies with different probiotic and synbiotc preparations, and well‐conducted meta‐analyses are also available. Majority of the published studies revealed that the probiotics can reduce the duration of diarrhoea by approximately one day, shorten the initial phase of watery stools, and decrease the length of hospital stay. Current ESPGHAN/ESPID guidelines, which was published in 2014, recommended three probiotic strains: Lactobacillus GG, Saccharomyces boulardii, and Lactobacillus reuteri DSM 17938. In 2014, Latin American Guidelines have been published and includes these three probiotic strains. In 2015, Yale and Harvard Probiotic Workshop Group revised their recommendation and this 4th symposium highlighted that the Lactobacillus GG and Saccharomyces boulardii CNCM I‐745 in the treatment of children with acute infectious diarrhea. We performed a large clinical study for the purpose of the effects of different strains in children with acute infectious diarrhea (including 5 different arms, and enrolled more than 1200 children) showed that probiotic effects on acute infectious diarrhea starts at 24th hours of intervention and more accurate at 48th and 72nd hours of intervention. The effects of probiotics are also related with the severity of diarrhea (like requiring hospitalization) and the effects of probiotics are better and earlier in outpatients than the children required hospitalization due to acute infectious diarrhea. Approximately one day reduction for the duration of diarrhea and duration of hospitalization reduced the health care cost related with diarrhea. There are numerous mechanism of action have been suggested for probiotics in children with acute diarrhea. Recently we showed that S. boulardii treatment have some beneficial effect on the recovery of impaired intestinal microbiota in children with acute infectious diarrhea due to rotavirus. There are few reports about the effect of prebiotics on acute infectious diarrhea. Our recent study showed that inulin alone has no effect on the duration of diarrhea in children with acute infectious diarrhea. The effects of symbiotic preparations including prebiotics should be evaluated with or without prebiotics in further studied for the prebiotics potential effects on diarrhea in children.

All published studies, meta‐analysis and guidelines showed that probiotic effect on acute infectious diarrhea are strain specific, and it is not possible to extrapolate the positive or negative results of one probiotic/symbiotic preparations to another ones.