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HelixTalk Episode #73 - Don’t go with the flow: how antibiotics cause diarrhea and what you can do about it

Date posted: January 30, 2018, 6:00 am

In this episode, we discuss the efficacy and safety of probiotics for the prevention of antibiotic-associated diarrhea (AAD) and Clostridium difficile-associated diarrhea (CDAD).


Key Concepts

  1. All antibiotics can cause diarrhea, but certain antibiotics are much more prone to this adverse effect than others, such as amoxicillin/clavulanate, cefixime, and clindamycin.
  2. All antibiotics can cause Clostridium difficile-associated diarrhea.  Clindamycin is by far the worst culprit (and has a boxed warning just for this risk).
  3. Probiotics almost certainly decrease the risk of antibiotic-associated diarrhea and Clostridium difficile-associated diarrhea, but the data supporting this benefit is extremely heterogeneous.  There is not one single, large randomized controlled trial demonstrating benefit, but instead is supported by meta-analyses.
  4. There is no clear probiotic strain, dose, or duration that has convincingly shown benefit versus another regimen.  More expensive probiotic preparations are not necessarily better.
  5. If probiotics are initiated to prevent antibiotic-associated diarrhea, initiate the probiotic as soon as possible (ideally even before the first antibiotic dose).


  1. Hempel S, Newberry SJ, Maher AR, et al. Probiotics for the prevention and treatment of antibiotic-associated diarrhea: a systematic review and meta-analysis. JAMA. 2012 May 9;307(18):1959-69.
  2. Shen NT, Maw A, Tmanova LL, et al. Timely Use of Probiotics in Hospitalized Adults Prevents Clostridium difficile Infection: A Systematic Review With Meta-Regression Analysis. Gastroenterology. 2017 Jun;152(8):1889-1900.e9.
  3. Allen SJ, Wareham K, Wang D, et al. Lactobacilli and bifidobacteria in the prevention of antibiotic-associated diarrhoea and Clostridium difficile diarrhoea in older inpatients (PLACIDE): a randomized, double-blind, placebo-controlled, multicentre trial. Lancet. 2013 Oct 12;382(9900):1249-57.