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Probiotics: What Are They and Do They Really Help C. diff?

Common definitions for probiotics say something like this: probiotics are live microorganisms that may provide health benefits when ingested. Sound disgusting? It’s not really.

Think about all the foods that you choose to eat that intentionally use microorganisms because of their fermentation properties: yogurt, cheese, miso, sauerkraut…to name a few.

Granted, not all of these foods still contain live microorganisms by the time they reach your refrigerator. Pasteurization often sees to that. But, maybe we should consider eating more unpasteurized foods and making our own fermented dairy and vegetable products. After all, our ancestors did and they didn’t suffer from the same type of illnesses that we have today. Numerous medical conditions that plague us were unheard of by our great-grandparents. And many of these conditions have been associated with too few “healthy” gastrointestinal species and too many “bad guys.”

C. difficile is no exception. It is an opportunistic bacteria that does no harm as long as there are enough “healthy” bacteria to keep its growth in check. However, when given the opportunity to overgrow in the intestines, it will! So, if the problem is not C diff per se, but rather too few of the “good guys,” probiotics offer a wonderful way to replace some of the “healthy” bacteria.

How do they target C. diff?
Let’s explore how probiotics may be effective treatments for C. diff infections. First, many probiotic strains are known to secrete toxins --toxins that are selectively toxic to C. difficile spores. Now, that’s a good thing, because none of the antibiotics currently in our armamentarium are capable of eliminating C. difficile spores.

Second, many strains of probiotic bacteria are capable of secreting acidic substances (i.e. short chain fatty acids and peroxides). Normal conditions in the colon are not very acidic. However, if we can create acidic conditions in the colon, it is helpful in our fight because C difficile is not a happy camper when conditions are acidic. Additionally, some of the acidic substances secreted by probiotic bacteria (especially butyric acid) also possess anti-inflammatory properties. This property may help heal the damaged intestinal wall.

Third, successful probiotic therapy may simply be a matter of competitive exclusion. As a Penn State football fan, I like to use the football analogy to explain this. If Beaver Stadium has 100,000 seats, but 200,000 fans show up for Saturday afternoon kick-off, by default, half the people have to leave.

The same is true in the intestines. There are only so many places for bacteria to bind on the intestinal wall. Furthermore, there is only so much food to go around; bacteria living in our colons are largely living under starvation conditions. If you over-load the body with enough “good” guys, some of the “bad guys” have to leave.

A fourth, more general mechanism that might explain beneficial actions of probiotics in C difficile simply may have to do with the ways in which probiotics stimulate the immune system and increase our body’s production of protective antibodies --antibodies that may react against C. difficile and its toxins.

Lastly, while the majority of probiotic products are bacteria-based, one specific strain of a “friendly” probiotic yeast offers a unique quality in that this yeast probiotic secretes an enzyme that selectively inactivates C. difficile toxins. Even if C. difficile microbes are producing their harmful toxins, this yeast enzyme destroys the toxins before they can be harmful to us.

Where to find probiotics
Unless you are willing to dramatically alter your diet, you probably need to use some type of probiotic supplement in order to substantially fix your own gastrointestinal bacteria once they become disrupted--especially if the “bad guys” have already taken over.

Probiotic supplements are available as powders, capsules, yogurts, fermented milks, etc. Thousands of products are on the market. A few have been studied in clinical trials. Some products I recommend without hesitation. Some products I wouldn’t waste my money on. Some products I run from and wouldn’t give to my dog. With many more products, I simply haven’t formed an opinion and would simply have to say, “I don’t know. I haven’t seen any published studies and I don’t have any clinical experience with it.”

For the best chance of success
Although some probiotic manufacturers disagree and claim to have solved this problem, from what I read in the literature, from what the food bacteriologists tell me, and from independent laboratory analyses, refrigeration is key for maximal probiotic viability. Optimally, the products should be refrigerated during shipping from the manufacturer, refrigerated at the store when purchased, and refrigerated in your kitchen.

I suspect a common problem that many folks make is simply not ingesting enough probiotics to do any good. It is estimated that each gram of fecal matter in the colon contains tens of trillions of bacteria! Think about that for a minute. If you only add a few million bacteria to your intestines, those couple-of-million bacteria won’t even make a dent in changing the overall intestinal environment! Successful clinical studies almost always use tens- or hundred- of billions of bacteria; I’ve even seen some studies that have reportedly used trillions of bacteria ingested each day. My personal rule of thumb is to recommend products that guarantee a minimum of 10 billion bacteria per dose. To be able to make that guarantee, these companies have to over-stuff their capsules initially to account for any bacteria that might die off between the time of manufacture and the expiration date. Keep in mind, too, that a single daily dose may not be enough. Depending upon the medical condition being treated and the severity of it, I may recommend taking 6 or 8 doses each day until the situation improves.

This “guarantee” of a minimum number of bacteria per dose brings up another interesting point. Many companies simply state on their label “’x’ number of bacteria per dose at time of manufacture”. Here’s the deal on this. I don’t care how many bacteria they put in there when they made the stuff, I want to see a product expiration date that guarantees me a set amount of bacteria until the product expires. Having an expiration date also, at least in principle, suggests that the company is doing some quality control studies on their product. Its an added plus if the company can provide documentation that an independent laboratory is providing quality control tests and can guarantee that there are no harmful bacterial contaminants.

Experts estimate that our intestines are home to approximately 400-500 different types of bacteria. Experts also agree that, when trying to repopulate the gut with “good guys”, it is wise to select a product that contains several different strains of bacteria as opposed to only one. Personally, I also prefer to use probiotics that were initially identified from healthy humans. At least I know, then, that those species of bacteria I choose to ingest intentionally are supposed to be there.

And finally, a few more practical considerations to keep in mind:

-Take your probiotic on an empty stomach. This means one hour before eating or two-to-three hours after meals.

-Take your probiotic with non-chlorinated water or milk.

-If taking antibiotics simultaneously with probiotics, separate your probiotic as many hours as possible away from your dose of antibiotic. By the way, some experts recommend when initiating probiotic therapy for C. difficile, that it may be wise to overlap your antibiotic (i.e. metronidazole or vancomycin) and probiotic therapy for 10 days. This allows your antibiotic to “beat down” the C. diff as much as possible, while beginning to repopulate your intestines with the “healthy guys.”

-It is common to experience transient flatulence (i.e. gas) when starting probiotics. Don’t stop the product if you experience gas, burping, or bloating. These symptoms are actually good. They are signs that the probiotic you are taking is alive and working. Too many people stop probiotic therapy too soon. The gastrointestinal discomfort usually subsides in 5-10 days and tends to be worse the more disrupted your own gastrointestinal bacteria are.

Finally, but unfortunately, there are no guarantees. Probiotics have helped many. They saved my son’s life when he was a toddler. Probiotics have been shown in clinical studies to both prevent and treat C. difficile diarrhea, but every body is different. If there was one “miracle” cure for everyone, we’d already have heard about it. The “healthy” bacteria that your body is missing may be different than someone else’s. The best thing you can do is stay informed, make healthy choices, and work together with your physician to find the cure that works for you!

Written by Kelly Dowhower Karpa, PhD, RPh. Additional probiotic information can be found in her book entitled Bacteria for Breakfast: Probiotics for Good Health.