Synopsis of the course

Explore the intricate relationship between antibiotics and the human microbiome in this CME course, updated with the latest evidence in the field. Providing you with a more practical approach, the course now includes a clinical case revealing the profound impact of antibiotic therapy on gut health, and how relevant the knowledge acquired in this course will be to your clinical practice.

Understand how dysbiosis, characterized by microbial imbalance, underpins various gastrointestinal and systemic disorders.

Updated with cutting-edge research, discover novel insights into antibiotic-associated dysbiosis and its far-reaching consequences on patient health. Equip yourself with evidence-based strategies to mitigate dysbiosis-related complications and optimize patient outcomes. Join us to navigate the evolving landscape of drug-microbiome interactions in clinical practice.

Who is professor Guarner ?

• Francisco Guarner, MD, PhD. has a degree in Medicine and Surgery and specialized in Digestive Diseases.
• He carries out his professional activity in the Digestive Pathology Service of the Universitari Vall d'Hebró Hospital.
• He has been a research fellow at the Liver United at Kings College Hospital in London and a research fellow in the Prostaglandin Research department of Welcome Research Laboratories.
• He is currently a member of the Centre of Network Biomedical Research of hepatic and digestive diseases as principal investigator of the inflammatory bowel diseases group and a member of the Board of Directors of the International Scientific Association for Probiotics and Prebiotics.
• He is also president of the Board of Directors of the Probiotics and Prebiotics Spanish Society, member of the Guidelines & Publications Committee of WGO-OMGE (World Gastroenterology Organization) and member of the Steering Committee of the International Human Microbiome Consortium (IHMC).

Conflict of Interest Disclosure: Francisco Guarner receives research funding from Abbvie, Takeda and AB-Biotics, and consulting fees from the Danone Institute, Sanofi, Biocodex, Actial, Menarini and Ordesa.

What is Xpeer?

Xpeer Medical Education is the first accredited medical education app in the market, with video microlearning engaging videos of just 5 minutes.

With a powerful algorithm to personalize the user experience and the contents as the most popular entertaining streaming platforms, it offers a brand new experience for the continuing education and professional development of the healthcare professionals.

Accredited by the European Union of Medical Specialists, it delivers high quality scientific medical education pieces. On Xpeer, you will find this curriculum on Microbiota and 500 hours of medical education in 2021 in your specialty, technologies and professional and personal skills.

Information on accreditation

The app Xpeer is accredited by the European Accreditation Council for Continuing Medical Education (EACCME) to provide official ECMEC credits recognized officially in 26 countries.

The credits for the users of the module will be 1 European CME credit (ECMEC®) for every hour (60 minutes of actual e-learning excluding introductions etc.) of use, provided that the users have completed a module and have passed the relevant assessment.

The Gut Microbiome in Immuno-Oncology

Join Dr. Arielle Elkrief in this free CME-accredited course as she explores the role of the gut microbiome in shaping response and resistance to immune checkpoint inhibitors in patients with solid tumors.

Gut microbiota in the management of gastrointestinal symptoms

Join Dr. Eamonn Quigley, in this free continuing medical education course, as he reviews the latest and most intriguing data on "the interaction between the microbiota and gastrointestinal symptoms".

Microbiota in intimate woman health through the lifespan

Gynecologists, midwives, and pharmacists, get free training on "Microbiota in intimate woman health through the lifespan" from Professor Alessandra Graziottin in this CME course.

Health outcomes of drugs-gut microbiota interactions

Get free training on drug-gut microbiota interactions from Professor Francisco Guarner in this updated CME course. This version includes the latest evidence in the field, as well as a clinical case study.

The rationale behind why and how to choose a probiotic

Get free training on decision-making for choosing a probiotic from Mary Ellen Sanders, a consultant in probiotic microbiology. Delve into this course based on clinical recommendations and provide your patients with the best approach. Learn more!

Early establishment of gut microbiota

Get free training on the early establishment of gut microbiota in this CME course, guided by Ericka Montijo. In this course, you will learn about the evolution and importance of the gut microbiota throughout our life. 

Detection, Prevention and Treatment of Gut Microbiome Dysbiosis

Learn how to detect, prevent and treat the gut microbiome dysbiosis in this free CME course led by renowned gastroenterologist, Prof. Francisco Guarner.

Gut Microbiota and metabolic disease

Join renowned expert Prof. Karine Clément, professor of nutrition, as she guides you through the "relationship between the gut microbiota and metabolic diseases". Get trained for free here !

Information on accreditation:

The app Xpeer is accredited by the European Accreditation Council for Continuing Medical Education (EACCME) to provide official ECMEC credits recognized officially in 26 countries.

The credits for the users of the module will be 1 European CME credit (ECMEC®) for every hour (60 minutes of actual e-learning excluding introductions etc.) of use, provided that the users have completed a module and have passed the relevant assessment.

With Xpeer you have 

• A Reliable Expertise: You will get trained by recognized experts, up-to-date and non promotional contents.
• International access: Do you prefer another language than English? No worries, all the sessions are subtitled in 7 languages: English, French, Spanish, Russian, Polish, Turkish and, Portuguese.
• Accrediting Courses: You will get instant credits! Xpeer is accredited by EACCME and you can convert EACCME credit to AMA credit.
• Easy to use format: You don’t need a « how to use » guide. You can access it on your phone with micro-learning sessions and videos.
• Free subscriptions: You don’t have to spend a penny! All the courses are free and directly available on the Xpeer app.

Are we destined to keep our extra pounds?

Broadly speaking, belief in a miracle cure is delusional. No treatment can beat obesity without the active participation of the subjects (diet, exercise, etc.) and an integrated and personalized approach to their care. Obesity is a long-term complex condition that depends on multiple related factors, including gut microbiota. However, to claim that an imbalance (sidenote: Dysbiosis Generally defined as an alteration in the composition and function of the microbiota caused by a combination of environmental and individual-specific factors. Levy M, Kolodziejczyk AA, Thaiss CA, et al. Dysbiosis and the immune system. Nat Rev Immunol. 2017;17(4):219-232.   ) in the microbial ecosystem inevitably leads to obesity (or conversely that a balanced one ensures a normal weight) is a mistake. It is nonetheless a good idea to maintain a balanced gut microbiota, which is part of a comprehensive and personalized treatment for patients.

Is it risky to act on microbiota on one’s own?

From a strictly medical standpoint, the approach is relatively safe, provided that consumers choose a probiotic¹⁷ whose advanced effects are based on scientific proof and whose bacterial composition is known (Lactobacilli (sidenote: Lactobacilli Rod-shaped bacteria whose main characteristic is the production of lactic acid, from where they get the name “lactic acid bacteria”.  Lactobacilli are present in the oral, vaginal and gut microbiota of humans, but also in plants and animals. They are found in fermented foods, such as dairy products (e.g. certain cheeses and yoghurts), pickles, sauerkraut, etc. Lactobacilli are also found in probiotics, with certain species recognized for their beneficial properties.   W. H. Holzapfel et B. J. Wood, The Genera of Lactic Acid Bacteria, 2, Springer-Verlag, 1st ed. 1995 (2012), 411 p. « The genus Lactobacillus par W. P. Hammes, R. F. Vogel Tannock GW. A special fondness for lactobacilli. Appl Environ Microbiol. 2004 Jun;70(6):3189-94. Smith TJ, Rigassio-Radler D, Denmark R, et al. Effect of Lactobacillus rhamnosus LGG® and Bifidobacterium animalis ssp. lactis BB-12® on health-related quality of life in college students affected by upper respiratory infections. Br J Nutr. 2013 Jun;109(11):1999-2007. ) and Bifidobacteria (sidenote: Bifidobacterium A genus of Y-shaped bacteria, most species of which are beneficial to humans. They are found in the gut of humans, and in some yogurts.

They:
- Protect the gut barrier 
- Participate in the development of the immune system and help fight inflammation 
- Promote digestion and improve symptoms of gastrointestinal disorders Sung V, D'Amico F, Cabana MD, et al. Lactobacillus reuteri to Treat Infant Colic: A Meta-analysis. Pediatrics. 2018 Jan;141(1):e20171811.  O'Callaghan A, van Sinderen D. Bifidobacteria and Their Role as Members of the Human Gut Microbiota. Front Microbiol. 2016 Jun 15;7:925. Ruiz L, Delgado S, Ruas-Madiedo P, et al. Bifidobacteria and Their Molecular Communication with the Immune System. Front Microbiol. 2017 Dec 4;8:2345. ) for example). It is a myth to think that all probiotics are the same as the specific bacterial strain used plays a critical role in their action. Lastly, the consumption of prebiotics¹⁸ should also be encouraged. However, new users should particularly avoid taking excessively high doses as they might experience unpleasant side effects such as bloating, diarrhea, abdominal pain, etc. If truth be told, the greatest risk is a psychological one—namely being disappointed if promises are broken!

Has gut microbiota transplant been oversold?

Many studies are currently underway on the topic. Some of them show that transplanting microbiota would have no effect on obesity or that it would result in a temporarily improved ability to stabilize blood sugar levels. Results have been disappointing, but provided much valuable information. We now know that donor and recipient microbiota must be compatible. We have also learned that some individuals are more receptive than others to transplant (the same goes for dietary changes) depending on the initial composition of their microbiota. In any event, improving our health by focusing on gut microbiota is a promising avenue, as long as we act reasonably and follow medical and dietary recommendations. Personally, I am convinced of it as my motto is “In Gut We Trust”.

Fecal microbiota transplant (FMT), also known as stool transplant, is another method which may well prove promising¹⁶. Currently prescribed to treat a sole condition far removed from obesity (recurrent Clostridium difficile infections), the procedure consists in this case in transferring microorganisms (sidenote: Microorganisms Living organisms that are too small to be seen with the naked eye. They include bacteria, viruses, fungi, archaea and protozoa, and are commonly referred to as “microbes”. What is microbiology? Microbiology Society. ) contained in the stool of donors with normal BMI to obese recipients to “correct” their flora¹⁷.

Several research teams are currently exploring the potential value of this approach. They are thoroughly examining its effect on gut microbiota restoration, eating behavior and the proper use of energy resources based on calories consumed¹⁷.

It’s the same story for prebiotics. These non-digestible sugars— present in vegetables, whole-grain cereals, legumes, tubers, fruits, nuts, herbs, spices, etc.—nourish good bacteria allowing them to proliferate to the detriment of bad bacteria. While their benefits in combating obesity have been widely demonstrated in the laboratory, human studies have produced divergent results⁶.

Some prebiotics induced a significant reduction in weight, BMI and waist circumference in obese and overweight adults, while others had no effect⁶.

As a whole, studies show that prebiotics affect satiety⁷, but unfortunately this does not lead to weight loss⁶. Although prebiotics remains an exciting line of research, experts agree that it is still too early to recommend their use in treating obesity and excess weight⁶.

To study their effect on weight loss, the body’s ability to regulate blood sugar levels despite a fatty diet, the feeling of satiety, the drop in the body mass index (BMI), the decline in fat mass, etc., laboratory mice were examined from every angle after being fed probiotics^3,4,6,14,15.

One of the results was that some lactobacilli (sidenote: Lactobacilli Rod-shaped bacteria whose main characteristic is the production of lactic acid, from where they get the name “lactic acid bacteria”.  Lactobacilli are present in the oral, vaginal and gut microbiota of humans, but also in plants and animals. They are found in fermented foods, such as dairy products (e.g. certain cheeses and yoghurts), pickles, sauerkraut, etc. Lactobacilli are also found in probiotics, with certain species recognized for their beneficial properties.   W. H. Holzapfel et B. J. Wood, The Genera of Lactic Acid Bacteria, 2, Springer-Verlag, 1st ed. 1995 (2012), 411 p. « The genus Lactobacillus par W. P. Hammes, R. F. Vogel Tannock GW. A special fondness for lactobacilli. Appl Environ Microbiol. 2004 Jun;70(6):3189-94. Smith TJ, Rigassio-Radler D, Denmark R, et al. Effect of Lactobacillus rhamnosus LGG® and Bifidobacterium animalis ssp. lactis BB-12® on health-related quality of life in college students affected by upper respiratory infections. Br J Nutr. 2013 Jun;109(11):1999-2007. ) , bifidobacteria (sidenote: Bifidobacterium A genus of Y-shaped bacteria, most species of which are beneficial to humans. They are found in the gut of humans, and in some yogurts.

They:
- Protect the gut barrier 
- Participate in the development of the immune system and help fight inflammation 
- Promote digestion and improve symptoms of gastrointestinal disorders Sung V, D'Amico F, Cabana MD, et al. Lactobacillus reuteri to Treat Infant Colic: A Meta-analysis. Pediatrics. 2018 Jan;141(1):e20171811.  O'Callaghan A, van Sinderen D. Bifidobacteria and Their Role as Members of the Human Gut Microbiota. Front Microbiol. 2016 Jun 15;7:925. Ruiz L, Delgado S, Ruas-Madiedo P, et al. Bifidobacteria and Their Molecular Communication with the Immune System. Front Microbiol. 2017 Dec 4;8:2345. ) , other bacteria with complicated names (Akkermansia, Hafnia, Pediococcus, Bacteroides,etc.) as well as a yeast, came out on top. Mice treated with these probiotics showed an improved metabolic profile and reduced weight gain^6,14,15. One of them even had a promising appetite-suppressant effect and contributed to the feeling of satiety.

There is less data on humans, and only some specific probiotics had an impact on weight, BMI, waist circumference, fat mass and metabolic profile^3,4,6. Despite these encouraging results, more research is needed to find out whether humans respond in the same way^3,6.

Diet is both the leading risk factor for obesity and the main lever in gut microbiota modulation. Unsurprisingly, the composition of the gut is shaped by dietary preferences. For example, omnivores have a higher diversity of bacteria compared to vegetarians. Similarly, microbiota is dominated by certain specific species in consumers of animal fat and protein, etc³. In theory, it seems easy to “remedy”...

Wrong!

Responses vary from person to person. Despite a great number of studies, no direct link has currently been established between action on the flora and the amount of weight loss¹¹. Some researchers believe that initial composition of our gut microbiota explains the variability in responses to diet^7,11 while others feel that it is even a good predictor of success⁷.

Among this controversy, only one thing is certain—healthy eating matters, even if some of us gain weight more easily than others!

The gastrointestinal tract is populated by bacteria, viruses and fungi. Among them, the two dominant bacterial phyla (Bacteroidetes and Firmicutes, including lactobacilli (sidenote: Lactobacilli Rod-shaped bacteria whose main characteristic is the production of lactic acid, from where they get the name “lactic acid bacteria”.  Lactobacilli are present in the oral, vaginal and gut microbiota of humans, but also in plants and animals. They are found in fermented foods, such as dairy products (e.g. certain cheeses and yoghurts), pickles, sauerkraut, etc. Lactobacilli are also found in probiotics, with certain species recognized for their beneficial properties.   W. H. Holzapfel et B. J. Wood, The Genera of Lactic Acid Bacteria, 2, Springer-Verlag, 1st ed. 1995 (2012), 411 p. « The genus Lactobacillus par W. P. Hammes, R. F. Vogel Tannock GW. A special fondness for lactobacilli. Appl Environ Microbiol. 2004 Jun;70(6):3189-94. Smith TJ, Rigassio-Radler D, Denmark R, et al. Effect of Lactobacillus rhamnosus LGG® and Bifidobacterium animalis ssp. lactis BB-12® on health-related quality of life in college students affected by upper respiratory infections. Br J Nutr. 2013 Jun;109(11):1999-2007. ) ) represent nearly 90% of the gut microbiota³. The remaining 10% consists of Proteobacteria (including Escherichia coli, known to be sometimes harmful) and Actinobacteria, including beneficial bifidobacteria (sidenote: Bifidobacterium A genus of Y-shaped bacteria, most species of which are beneficial to humans. They are found in the gut of humans, and in some yogurts.

They:
- Protect the gut barrier 
- Participate in the development of the immune system and help fight inflammation 
- Promote digestion and improve symptoms of gastrointestinal disorders Sung V, D'Amico F, Cabana MD, et al. Lactobacillus reuteri to Treat Infant Colic: A Meta-analysis. Pediatrics. 2018 Jan;141(1):e20171811.  O'Callaghan A, van Sinderen D. Bifidobacteria and Their Role as Members of the Human Gut Microbiota. Front Microbiol. 2016 Jun 15;7:925. Ruiz L, Delgado S, Ruas-Madiedo P, et al. Bifidobacteria and Their Molecular Communication with the Immune System. Front Microbiol. 2017 Dec 4;8:2345. ) ³. A well-balanced gut microbiota contributes to good health and a number of processes. It aids digestion and proper intestinal cell function, interacts with the immune system, prevents invading molecules and bacteria from crossing the gut epithelium and also communicates with the brain. In obese and overweight individuals, the gut microbiota seems to be unbalanced (dysbiosis (sidenote: Dysbiosis Generally defined as an alteration in the composition and function of the microbiota caused by a combination of environmental and individual-specific factors. Levy M, Kolodziejczyk AA, Thaiss CA, et al. Dysbiosis and the immune system. Nat Rev Immunol. 2017;17(4):219-232.   ) ). This means it is generally less abundant and diverse⁹ with a reduction of beneficial bacterial species such as Akkermansia muciniphila and bifidobacteria (sidenote: Bifidobacterium A genus of Y-shaped bacteria, most species of which are beneficial to humans. They are found in the gut of humans, and in some yogurts.

They:
- Protect the gut barrier 
- Participate in the development of the immune system and help fight inflammation 
- Promote digestion and improve symptoms of gastrointestinal disorders Sung V, D'Amico F, Cabana MD, et al. Lactobacillus reuteri to Treat Infant Colic: A Meta-analysis. Pediatrics. 2018 Jan;141(1):e20171811.  O'Callaghan A, van Sinderen D. Bifidobacteria and Their Role as Members of the Human Gut Microbiota. Front Microbiol. 2016 Jun 15;7:925. Ruiz L, Delgado S, Ruas-Madiedo P, et al. Bifidobacteria and Their Molecular Communication with the Immune System. Front Microbiol. 2017 Dec 4;8:2345. )  and an increase in potentially harmful bacteria that contribute to weight gain through yet-tobe- understood mechanisms.⁹.

The vicious cycle of dysbiosis

Be it the cause or the consequence, gut microbiota plays a role in obesity. When altered, there are many health implications including digestive disorders, impaired defense mechanisms and its reduced capacity to communicate with the brain to control hunger⁸. These disturbances in turn maintain gut microbiota dysbiosis⁹. More than just a metabolic disorder, obesity would therefore be associated with brain and immune system dysfunction which manifests itself in abnormal eating behaviors in which gut microbiota plays a role^3,4,8,10.

Let us explain!

Recent and planned studies are focused on the evaluation of other potential risk factors during pregnancy and after early infancy. Intrapartum antibiotics are extensively used worldwide for the prevention of maternal infection associated with C/S birth and prevention/management of Group B streptococcal (GBS) infections.

Stearns et al.’s recent study, which was published in Scientific Reports (2017) [1], entitled “Intrapartum antibiotics for GBS prophylaxis alter colonization patterns in the early infant gut microbiome of low risk infants”, is an important example of the effects of antibiotics on intestinal microbiota composition in healthy, term, breastfed infants. In this study, the authors investigated the microbiota composition in 53 infants born vaginally, with no exposure to antibiotics; of these, 14 infants were exposed to intrapartum antibiotic prophylaxis for Group B Streptococcus, and seven infants were born by C-section (in Canada). Overall, the intestinal microbiota of infants born vaginally without exposure to intrapartum antibiotic prophylaxis differed significantly from that of infants born vaginally but exposed to intrapartum antibiotic prophylaxis for GBS or infants born by C-section (also exposed to IAP).

Regarding the results of this study, the faecal microbiota of intrapartum antibiotic prophylaxis-exposed infants exhibited significantly lower alpha diversity, and intrapartum antibiotic prophylaxis for GBS exposure during vaginal birth might therefore affect the Bifidobacterium levels/ predominance (delay in expansion) over the first 12 weeks of life. This study also showed that colonization of the infant gut microbiota differs in the distribution of bacteria, similar to the majority of published studies on the effect of delivery mode on infant intestinal microbiota composition.

This study found that intrapartum antibiotic prophylaxis for GBS affected all aspects of gut microbial ecology including species richness, diversity, community structure, and the abundance of colonizing bacterial genera. These study results also showed that antibiotic prophylaxis for any purpose may affect infant intestinal microbiota composition and this highlights the importance of appropriate antibiotic use.

In 2016, Cassidy-Bushrow and colleagues published a report on an association between maternal Group B streptococcus and infant gut microbiota [2]. In this study, as part of a population-based, general- risk birth cohort, stool specimens were collected from infants’ diapers at one and six months of age. The authors showed that maternal GBS status was statistically significantly associated with gut bacterial composition in the sixth month, and infants of GBS positive mothers were significantly enriched for Clostridiaceae, Ruminococcoceae, and Enterococcaceae also in the sixth month. In addition, Mazzola et al. demonstrated the short-term consequences of maternal intrapartum antibiotic prophylaxis, to prevent GBS infection, on the faecal microbial population in infants, particularly in breastfed infants [3]. The long-term effects on intestinal microbiota composition have not been addressed in previous studies.

Altered microbiota composition has been associated with obesity, allergy, inflammatory bowel disease, and colon cancer, and further studies are needed to define causal effects. These results also highlight the unmet medical need for maternal immunization using potential GBS vaccines.

Introduction to the gut microbiota

Gut microbiota, the largest human organ, has 10 times more cells (1014) than the human cells in the body (1013) [2]. The functions of the GM include, digestion of food, metabolism of the drugs and toxins and their detoxification, vitamin synthesis, prevention of attachment of pathogenic bacteria to the gut wall, modulation of immune, neuro-hormonal, central nervous system functions [2]. Considering the diverse functions of the GM, its alteration is expected to be associated with several diseases and its modulation to be beneficial.

Role of gut microbiota in colorectal cancer

Microbes are well-known to cause several cancers (Figure 1) [3]. Recently, emerging data suggest the role of dysbiosis in CRC. Fecal microbiota of patients with colonic polyposis resembles that of CRC. Whereas Clostridium spp., Bacteroides and Bifidobacterium spp. are associated with CRC, lactic acid-producing bacteria (e.g. Lactobacillus spp. and Eubacterium aerofaciens) are negatively associated. GM associated production of methane, H2S, and presence of Streptococcus bovis may play role in CRC development. Obesity, recently thought to be related to GM, is a predisposing factor for CRC.

Gut microbiota & obesity

Calorie extraction from foods not only depends on digestive function of the small bowel, but also on the extraction of malaborbed calorie by the colonic microbiota. Whereas presence of Firmicutes is associated with greater calorie extraction, Bacteroidetes have opposite effect [4]. Examples from the Nature include development of obesity in elephants in spite of their low-calorie diet. In animal husbandry, use of low-dose antibiotic from the childhood increases the amount of meat. The difference in the fecal microbiota among obese and non-obese individuals have been shown. In a retrospective cohort study from the UK, of 21,714 infants, 1306 (6%) became obese at 4-y of age. On logistic regression analyses adjusting for mothers’ and sibs’ obesity, maternal diabetes, mode of delivery, socioeconomic status, year and country of birth, and urban dwelling, antibiotic exposure before 2-y age was associated with development of obesity and the number of exposure correlated with it [5].

Other metabolic syndromes including nafld, coronary artery disease, & diabetes mellitus

NAFLD, associated with metabolic syndrome may have dysbiosis including a quantitative increase in upper gut bacteria (SIBO ≥105 colony forming unit, CFU/mL, and low-grade ≥103 CFU/ mL) [6].An uncontrolled and three casecontrol studies showed SIBO to be associated with NAFLD [6]. Two studies showed lower relative abundance of Bacteroidetes, and higher abundance of C. coccoides, and Prevotella in NAFLD patients. Higher extraction of calorie from unabsorbed complex carbohydrates, insulin resistance and endogenous production of alcohol may contribute to the pathogenesis of NAFLD due to dysbiosis.

GM plays important role in glucose metabolism, insulin resistance, diabetes, and has implication in its treatment. Patients with diabetes have different fecal microbiota than the control population [4]. GM was shown to be an important factor regulating glucose levels after intake of different foods independent of physical exercise, lifestyle, and anthropometric measures [7]. Metformin, an oral hypoglycemic, may partly work by altering the GM. Though studies on the role of GM on coronary artery disease are scanty and results mixed, data suggesting its role in this condition is emerging.

Antibiotic misuse in Asia

Antibiotic use is high in Asia and the implementation of policies for appropriate use is poor, with risk of emergence of antibiotic-resistant “super-bug”.Reasons for misuse of antibiotics include, unrestricted availability, and use in inappropriate indications e.g. common cold, acute gastroenteritis due to non-invasive pathogens. Use of probiotics, when indicated, may help to contain misuse of antibiotics.

Manipulation of gut microbiota using agents other than antibiotics

Though GM manipulation using rifaximin is well-known, probiotics and fecal transplantation have potential to treat dysbiosis associated disorders, e.g. antibiotic-associated diarrhea (AAD), IBD, IBS, Clostridium difficile-associated diarrhea (CDD), and as a co-prescription during anti-H. pylori treatment. ACG made a weak recommendation (from 23 randomized controlled trials, RCTs) that probiotics improve global symptoms, bloating, and flatulence in IBS [8]. A Cochrane review showed probiotics to be useful for preventing CDD [9]. A metaanalysis showed multi-species probiotics to induce and maintain remission in UC, though data on Crohn’s are scanty [10]. Shorter anti-H. pylori treatment duration is well-known to reduce frequency of its eradication; meta-analyses showed that probiotic co-administration increase the eradication rates due to lower adverse effects and better compliance [9]. H. pylori eradication treatment may lead to fecal dysbiosis and co-administration of probiotics may restore eubiosis.

Future directions

In an attempt to form an Asia-Pacific Consortium on GM similar to European and North American groups, and to review the current evidence supporting manipulation of GM using probiotics in gastrointestinal disorders in the Asia- Pacific region, a consensus has been developed and published recently [9]. The major conclusions of this consensus were: there is growing evidence to support the therapeutic potential of probiotics in modulating gastrointestinal functions and relieving symptoms of these disorders, but more research is needed both in Asia- Pacific regions and internationally [9].