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ii.
iii. Streptococcus: lactis, cremoris, alivarius, intermedius iv. Leuconostoc v. Pediococcus vi. Propionibacterium
vii. Bacillus viii. Enterococcus ix. E. faecium B. Yeast and moulds A. cerevisiae, A. niger, A. oryzue, C. Pintolopesii, Sacharomyces boulardii. A bacteria, before being selected as a probiotic, should be non-pathogenic, non-toxigenic, should retain viability during storage and use, should have the capacity to survive and metabolise in the gut, and finally should have documented health effects. L. rhamnosus strain GG meets most of these criteria.
* Assistant Professor, Department of Medicine, ** Associate Professor, Department of Paediatrics, Maulana Azad Medical College, New Delhi - 110 002.
Table II : Indications for probiotics5. Proven indications Rotavirus diarrhoea Reduction of antibiotic-associated side effects Food allergies and lactose intolerance Atopic eczema Prevention of vaginitis Urogenital infections Irritable bowel syndrome Inflammatory bowel disease Cystic fibrosis Travellers diarrhoea Dental caries Enhance oral vaccine administration H. pylori infection Various cancers
Probiotics in Diarrhoea
Saavedra et al showed that supplementation of infant milk formula with B. bifidum and S. thermophilus reduced rotavirus shedding and episodes of diarrhoea in children in hospital10. In a study of HIV associated acute diarrhoea, Saint Marc reported that 56% of patients who were treated with S. boulardii had their symptoms resolved compared with only 6% of placebo treated patients11. Gorbach et al demonstrated that Lactobacillus GG successfully eradicated C. difficile in five patients with relapsing colitis, when they were fed viable lactobacilli in skimmed milk daily12. Further reduction in incidence of travellers diarrhoea has been reported by many studies13,14. These studies demonstrate that a probiotic can be effective in treating antibiotic induced diarrhoea, diarrhoeal disease acquired during travel, which most likely has a mixed bacterial and viral etiology, and diarrhoeal diseases in young children caused by rotavirus.
Possible indications
frequently occurring genetic alterations associated with human cancers, especially carcinoma of colon. Elevated levels of ras P-21 have been correlated with increased cell proliferations, histologic grade, nuclear aplasia and degree of undifferentiation18. Reddy et al demonstrated that dietary B. longum cultures significantly suppressed the expression of total and neonated ras P-21 in the colonic mucosa and tumours compared with control diet19. An additional mechanism of tumour suppression may involve a role for B. Longum as an immunomodulator and biological response modifier20. Probiotics also stimulate apoptosis through end-product formation.
organism with varying results26,27. The role of Lactobacillus casei strain GG (LGG) in IBS was studied in a randomised double blind cross-over trial28. The authors concluded that LGG alone did not have an effect on symptoms of IBS. The evidence of the use of probiotic bacteria in IBS is so far inconclusive. The trials that have been performed have centred on a symptomatic reduction or cure and have produced varying results. Currently, no organism can be confidently recommended to patients as being likely to help their symptoms. However, the abnormalities seen in colonic flora of IBS suggest that a probiotic approach will ultimately be justified.
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allergy to cows milk. At a mean age of 5.5 months, they were assigned in a randomised double blind manner to receive either extensively hydrolysed whey formula (placebo group) or the same formula supplemented with viable Lactobacillus GG (viable LGG group) or heat inactivated Lactobacillus GG (heat inactivated LGG group) respectively. Within the study population, atopic eczema and subjective symptoms were significantly alleviated in all the groups. It was concluded that supplementation of infant formulae with viable but not heat inactivated LGG is a potential approach for the management of atopic eczema and cow milk allergy.
Bacterial vaginosis
Essentially, bacterial vaginosis is considered as an overgrowth of anaerobic organisms combined with a loss of the protective lactobacilli normally found in the healthy vagina35. Recently, daily oral intake of probiotic strains Lactobacillus rhamnosus GR-I and Lactobacillus fermentum RC-14, resulted in asymptomatic bacterial vaginosis patients reverting to normal lactobacilli dominated vaginal microflora 36,37. The mode of action might compromise increased ascension of probiotic and/or indigenous lactobacilli from the rectal skin to the vagina and enhancement of the intestinal mucosal immunity which effects vaginal immunity rendering the
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inflammatory bowel disease41. More clinical trials are needed to evaluate the true place of probiotics within a treatment regimen for chronic inflammatory bowel disease.
consumption of probiotic containing cheese and its effects on dental caries risk factors. Arch Oral Biol 2002; 47 (11): 799804. 5. 6. Gorbach SL. Probiotics in the third millennium. Dig Liver Dis 2002; 34 (Suppl 2): S2-7. Salminen S, Deighton M. Lactic acid bacteria in the gut in normal and disordered states. Dig Dis Sci 1992; 10: 227-38. Golden BR, Gorbach SL, Saxelin M et al. Survival of lactobacillus species (strain GG) in human gastrointestinal tract. Dig Dis Sci 1992; 37: 121-8. Seo G, Shimizu K, Kono M et al. Inhibition of growth of some enteropathogenic strain in mixed cultures of streptococcus faecalis and clostridium butyricum. Microbios Letter 1989; 40: 151-60. Lino H, Seo G, Shimuzu K et al. Stimulation of bacterial growth of some strain of Bifidobacterium by crude preparation of some strain of bifidobacterium by a crude preparation of metabolites from bacillus mesenteries. TOA Blome Letter 1993; 48: 73-8.
8.
9.
10. Saavedra JM, Bauman NA, Oung I et al. Feeding of bifidobacterium bifidum and streptococcus thermophilus to infants in hospitals for prevention of diarrhea and shedding of rotavirus. Lancet 1994; 344: 1046-9. 11. Saint Marc T, Rosse HO, Prats L, Touraine JL. Efficacit Saccharomyces boulardii dans let treatment des diarrheas di SIDA. Ann Med Intern (Paris) 1999; 142: 64-5. 12. Gorback SL, Chary T, Golden B. Successful treatment of relapsing clostridium difficle colitis with lactobacillus GG. Lancet 1987; (ii): 1519. 13. Black FT, Andersen PL, Orskov J et al. Prophylactic efficacy of lactobacilli on travellers diarrhea. In: Stiffen Re ed. Travel Medicine, conference on international travel medicine. Zurich Switzerland, Berlin: Springer, 1989; 333-5. 14. Oksanen PJ, Salminen S, Saxelin M et al. Prevention of travellers diarrhea by lactobacillus GG. Annals of Medicine 1990; 22: 53-6. 15. Kim HS, Gilliland SE. Lactobacillus acidophilus as dietary milk adjunct to aid lactose digestions in humans. Journal of Dairy Science 1983; 66: 959-66. 16. Kulkarni N, Reddy BS. Inhibitory effect of B Longum cultures on the azoxymethane induced aberrant crypt foci formation on focal bacterial beta-gluconidase. Proc Soc Exp Bid Med 1994; 207: 278-83. 17. Sekine K, Watanabe Sekine E, Ohta J et al. Induction and activation of tumoricidal cells in vitro and (in vivo by the bacterial cell wall of B infants). Bifidobacteria and Microflora 1994; 13: 54-77. 18. Kotsinas A, Spandidos DA, Romanowski P et al. Relative expression of wild type and activated ki-ras2 oncogene on colorectal carcinomas. Int J Oncol 1993; 3: 841-5. 19. Reddy BS, Riverson A. Inhibitory effect of B ongum on colon, mammary and liver carcinogenesis induced by 2 amino-3methylimidazo (4, 5-+) quinoline, a food mutagen. Cancer Res 1993; 53: 3914-8. 20. Okawa T, NiibeH, Arai T et al. Effect of LC 9018 combined
References
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with radiation therapy on carcinoma of the uterine cervix. Cancer 1993; 72: 1949-54. 21. Schiffrin, EJ, Brassart D, Serving AL et al. Immune modulation of blood leukocytes in human by lactic acid bacteria: Criteria for strain selection. Am J Nutr 1997; 66 (Suppl) 15: 205. 22. Berg RD. Translocation of indigenous bacteria from the intestinal tract, In: ed Hentges DJ, Human intestinal Microflora in health and diseases; 1983; New York; Academic Press 333-52. 23. Kleeman EF, Klaenhammet TR. Adherence of lactobacillus species to human fetal intestinal cells. J Parry Sci 1982; 65: 2063-9. 24. Halpern GM, Prindiville TS, Blankenburg M et al. Treatment of irritable bowel syndrome with Lacteol fort: a randomised, double blind, cross over trial. Am J Gastroenterol 1991; 1579-85. 25. Hunter JO, Lee AJ, King Ts et al. Enterococcus faecium strain PR88 - an effective probiotic. Gut 1996; 38 (Suppl 1): A62. 26. Niedzielin K, Kordecki H, Kosik R. New possibility in the treatment of irritable bowel syndrome: probiotics as a modification of the microflora of the colon. Gastroenterology 1998; 114: A402. 27. Nobaeck S, Johansson ML, Molin G et al. Alteration of intestinal microflora is associated with reduction in abdominal bloating and pain in patients with irritable bowel syndrome. Am J Gastroenterol 2000; 95: 1231-38. 28. OSullivan MA, O Morain CA. Bacterial supplementation in the irritable bowel syndrome. A randomised double blind placebo controlled cross over study. Dig Dis Sci 2000; 32: 302-4. 29. Loskutova IE. Effectiveness of using maluitka and Malysh adapted propronic acidophilus mixtures in the combined treatment of congenital hypertrophy. Vopr Pitan 1985; 1720. 30. Trapp CL, Charg CC, Halpern GM et al. The influence of chronic yogurt consumption on population of young and elderly adults. Int J Imunother 1993; 9: 53-64. 31. Yasui H, Nagaoka N, Mike A et al. Detections of bifidobacterium strains that induce large quantities of IgA. Microb Ecol Health Dis 1992; 5: 155-62. 32. Sutas Y, Hurme M, Isolauri. Down-regulation of anti-Co3 antibody induced IL-4 production by bovine caseins hydrolysed with LGG derived enzymes. Scand J Immunol 1996; 98: 216-24. 33. Kirjavainem PV, Salminen SJ, Isolauri E. Probiotic bacteria in the management of atropic disease: underscoring the importance of viability. JPGN 2003; 36 (2): 223-7. 34. Isolauri E, Joensuu J, Suomalainen H et al. Improved immunogenecity of oral Dx RRV reassortant rotavirus vaccine by L casei. GG vaccine 1995; 13: 310-2. 35. Sobel JD. Bacterial vaginosis. Annu Rev Med 2000; 51: 349-56. 36. Reid G, Bruce AW, Fraser N et al. Oral probiotics can resolve urogenital infections. FEMS Immunol Med Microbiol 2001; 30: 49-52. 37. Reid G, Charbonnaeau D, Erb J et al. Oral use of Lactobacillus
rhamnosus GR-1 and L. Fermentum RC-14 significantly alters vaginal flora: randomised placebo controlled trial in 64 healthy women. FEMS Immunol Med Microbiol 2003; 35: 131-4. 38. Bruce AW, Chadwick P, Hassan A et al. Recurrent urthritis in women. Can Med Assoc J 1973; 108: 973. 39. Reid G, Bruce AW, Taylor M. Instillation of Lactobacillus and stimulation of indigenous organisms to prevent recurrence of urinary tract infections. Microecology Therapy 1995; 23: 32-45. 40. Mann GV, Spoery A. Studies of a surfactant and cholesteremia in the maassai. Am J Clin Nut 1974; 23: 464-9. 41. Schultz M et al. Probiotics and inflammatory bowel disease. Am J Gastroenterol 2000; (1 Suppl): S19-21. 42. Gasser F. Safety of lactic acid bacteria and their occurrence in human clinical infections. Bulletin de L Institut Pasteur 1994; 92: 45-67. 43. Saxelin M, Chuang NH, Chassy B et al. Lactobacilli and bacteremia in southern Finland, 1989-1992. Clin Infect Dis 1996; 22: 564-6. 44. Wolf BW, Wheeler KB, Ataya DG, Garleb KA. Safety and tolerance of Lactobacillus reuteri supplementation to a population infected with human immunodeficiency virus. Food Chem Toxicol 1998; 36: 1085-94. 45. Cunnigham Rundler S, Ahrne S, Bengmark S et al. Probiotics and immune response. Am J Gastroenterol 2000; 95: S22-5. 46. Borriello SP, Hammes WP, Holzapfel W et al. Safety of probiotics that contain Lactobacilli or Bifidobacteria. Clin Infect Dis 2003; 36: 775-80.
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