Prof. Dr. R.V.S.N.

Sarma,
MD., M.Sc (Canada), RCGP, FCGP, FIMSA,
Senior Consultant Physician,
Cardio-Metabolic and Chest Specialist
Honorary National Professor of
Medicine (CGP)
visit: www.drsarma.in
www.youtube.com/user/drsarmaji

Antibotics
Probiotics
Prebiotics
Synbiotics
2

Potential benefits of
Lactobacillus~125 yrs ago

1905: Concept of Probiotics

3

Starts immediately after birth

Place of birth
Type of Delivery
Feeding: Time, Type
Pre-lacteals vs Exclusive breast feed.
Premature vs. Full term
Sick babies

1st Year;: > 200 bacterial species

Adult : 500-600 bacterial species

Elderly: 300 Bact. Species

Chr. Intestinal disorders

For context Total Cells

Theirs ~ 100,000 billion.
Ours ~ 10,000 billion.

Friendly bacteria
Unfriendly / harmful Bacteria

Probiotics
Pathogens

Facultative Anaerobes

Strict anaerobes

Staph. Aureus, albus

Nose & skin

Mouth, Colon, Vagina

Lactobacilus Sp, Bifidobact..

Candida albicans

Mouth, Colon, Vagina

Vagina, Outer urethra

E. Coli.

Haemophilus Sp.

Nasophyrinx & Conjunctiva

Pseudomonas aeruginosa

Colon & skin

LACTOBACILLUS: BIFIDOBACTERIA: SACCHAROMYECES:

Probiotics
(Friendly Bacteria)

Normalise
Intestine

Suppression of
PPMs

Immunomodulation

Strengthens
immunity

Metabolic effects

Production of vitamins;
improves digestion

Intestinal
mucosal integrity

Alleviate
food allergy symptoms

Lactose tolerance

Regulation of
bowel movement
IBS

Conrol of IBD

Lowers cholesterol
(Bile acid deconjugation
&Secretion)

Inhibit Potentially Pathogenic Microorganisms (PPMs)

Reduction in Intestinal pH ( through production of

SCFAs)

Production of bacteriocins

Competitive blocking of adhesion sites

Competition for nutrients

Most abundant Probiotic in

GI

Lactobacillus:

Acidophilus,

Rhamnosus, GG

Plantarum,

Reuteri,

Bulgaricus,

Sporogens

Casei

Action only in Small intestine

14

Bifidobacteria

32 different species : Longum, Bifidum, infantis etc

Most abundant probiotic next to lactobacilli Sp. in

the GIT

Action : Large Intestine

15

Apart from the general Probiotics effect ,

Bifidobacteria helps is Glutamine synthesis

Glutamine helps in maintaining the mucosal

integrity

NH3 + Glutamic acid ------------>

Bifidobacteria

Glutamine

Saccharomyeces:

Boullardii,

Salivarium,

Thermophilus

Non colonising yeast so needs

repeated readministration
Action in large intestine
17

1. Be nonpathogenic and nontoxic to the host

2. Be antagonistic to pathogens
3. Exert a beneficial effect on the host
4. Capable of surviving, colonizing and proliferating in the
gut (should not be killed by gastric juice / bile acids)
5. Able to inhabit in the S & L intestine
6. Must be of human origin
7. Contain a large number of viable cells and remain viable
during storage and use

Bifidobacteria is an Important Probiotic as it

maintains the mucosal integrity

Hence Bifidobacteria supplementation is useful in

conditions like Gastroenteritis where the GI mucosa
is severely damaged

However, all the marketed preparation contains only

1 3 species of Bifidobacteria as against 32
required

Hence it is ideal to supplement with probiotic which

give nutrient to Bifidobacteria so all 32 species can
proliferate

 Non-digestible dietary supplements, which provide

nutrition for Probiotics
Oligosaccharides (fructo-oligosaccharides or FOS),
Inulin, Lactulose, Lactitol
Mutated Bacterial Species (Streptococcus faecalis,
Clostridium butyricum, Bacillus mesentericus)
Advantage of Prebiotics in bacterial form : Addl.
Probiotic activity ( Intrinsic Probiotic activity)

 Supply nutrient to beneficial bacteria

Should escape digestion in the stomach and reach
Intestine
Should promote the proliferation of beneficial
bacteria (Lactiobaccillus , Bifidobacteria)

Probiotics
Nature Microorganism
of the
Prep
Prime
Fn

To kill harmful
pathogen

Prebiotics
Food supplement
(eg: FOS) or
Microorganism
(eg : S.F )
To supply nutrition
(Killing the
pathogen is an
additional effect)

FOS Recommended daily dose is 2 - 6 gm

Marketed prep. offer 100, 250 mg of FOS

Which is inadequate dose

Also at high dose , FOS cause flatulence and GI

discomfort

Hence using a live mutated bacteria is

beneficial as it would ensure the continuous
colony count (nutrient) with out any side effect

1. Infective diarrhea (viral, bacterial)

2. Antibiotic associated diarrhea
3. Lactose intolerance
4. Recurrent aphthous ulcers and stomatitis
5. Travelers diarrhea
6. Inflammatory IBD (Ulcerative colitis, Crohns)
7. Irritable bowel syndrome
8. Post operative state
9. Pouchitis
10. Diverticular disease of colon

Due to bacteria, Virus or Protozoa

Viral diarrhoea :
Rotavirus
Mx : ORS / Infusion

Bacterial Diarrhoea :
E.coli , Salmonella , Shigella , V. Cholerae
Mx : Antibacerial

Protozoal Diarrhoea :
E.Histolytics
Mx : Metrinadozole

An all the 3 types , there is a disturbance of the Intestinal

microflora. Hence supplementation with Bifilac normalises the
gut flora by displacing the PPMs and hence reduce the duration
of diarrhoea

Free
Free amino
amino acids
acids
Neutralization
Neutralization of
of

Organic
Organic acids
acids

dietary
dietary carcinogens
carcinogens

-Galactosidase
-Galactosidase activity
activity

Oligosaccharides
Oligosaccharides

Probiotics
Probiotics

Immunostimulator
Immunostimulator

olesterol
olesterol assimilation
assimilation
Antioxidant
Antioxidant
Short
Short chain
chain fatty
fatty acids
acids
Survival
Survival and
and adhesion
adhesion

Bioactive
Bioactive peptides
peptides
Bacteriocin
Bacteriocin

competitions
competitions with
with
pathogenic
pathogenic bacteria
bacteria

Adhesive

Non-adhesive

Microorganisms

M = M cells of intestinal epithelium

L = Lymphocytes

Immune Response

APC = Antigen presenting cells

Intestinal Epithelium

Th = T-helper cells
M

IL = Interleukines
TGF = Tumour growth factor
IFN = Interferon
TNF = Tumour necrosis factor

L
L

L
APC

Ig = Immunoglobulin

Th0
IgG
Cell
mediated
response

IL-2
IFN-

TGF-
IL-4
IL-10

Antibody
mediated
response

IgM
IgE

B
Th2

Th1

IgA
IL-2
IFN-
TNF-
IFN-
Natural killer cells
Macrophages
Cytotoxic T-lymphocytes

Viruses

Tumors

Protection of intestinal epithelial barrier

function

Regulation of intestinal epithelial

homeostasis

Regulation of intestinal microbial

environment

Modifications to commensal and probiotic

bacteria to enhance diarrhea prevention

Most common antibiotics that cause diarrhea

Alteration in composition of normal intestinal bacterial micro

flora by antibiotic makes the GI tract susceptible to infection
by fungus (Candida) or bacteria, Clostridium difficile

Fungus alters absorptive surface of GI tract diarrhea

24

Pseudomembranous Colitis

Volcano lesions in AAD

Relative risk of diarrhea reduced by 40 %. By LGG / Sacch

5-10 billion viable organisms X 3-4 times/day

Probiotics to be separated from Antibiotics by couple of H

31

 The incidence of AAD can go up to 26% of

patients on antibiotics,
Broad-spectrum antibiotics are associated
with the highest rate of AAD because of
their disruptive impact on the normal
intestinal flora.

7
6-60
0
6
,
6) 3
(200

Almost all antibiotics, particularly those that act on

anaerobes, can cause diarrhea, but the risk is higher with
aminopenicillins, a combination of aminopenicillins and
clavulanate, cephalosporin's, and clindamycin.
Diarrhea is a common adverse effect of antibiotic
treatments.
Antibiotic associated diarrhea
in about (8
5-30%
BMJoccurs
2002;324:1345-1346
JUNE)
of patients

International Microbiology 2004 ; Mar 7

35

36

 Lactase digests lactose commonly present in milk and milk

products.
Lactose is not digested when there is a deficiency in lactase
and results in diarrhea.
Supplementation with probiotics has been shown to mitigate
the symptoms of lactose intolerance.

 Superficial ulcers or fissures in

mucosa of mouth.
Painful condition.
Each episode lasts 8 -14 days.
Exact etiology not known.
Stress appears to play a role.
Mx : B complex / multivitamin,
probiotics and antiseptic or
tetracycline mouth wash.

 Transmission of infection:
Feco-oral route / fingers and flies.
Affects tourists traveling ; Shigella
Travelers diarrhea can be prevented by regular prophylactic
intake of beneficial bacteria
One week before travel, during travel, one week after
completion of travel.

Chronic medical condition characterized by

abdominal pain, discomfort and results in change
in the bowel frequency & consistency in the stools

Cause : Alteration in the bowel motility & transit (

due to anxiety)

Symptoms : Bloating , gas , dyspepsia ,

constipation, diarrhea , diarrhea alternating with
constipation, dysentery

Inflammation in GI Tract

Crohns Disease

Ulcerative Colitis

Small & Large intestine

Large intestine (Rectum & Colon)

Crohns disease

Ulcerative colitis

Symptom : Diarrhoea / Dysentery / fever / Wt.loss

Rx : Sulphasalazine , Steroids , Immuno-suppresants

Rationale for Probiotic : IBD patients have a

compromised bowel flora due to inflammation.
Supplementation with probiotic helps to normalize
the bowel flora and there by reduces the inflammation

Probiotics promotes the antigen specific IgA immune

response and shortens the diarrheal phase .
Also reduces the relapse rate

 Inflammation of an internal pouch created in patients who

have part of their colon removed to treat ulcerative colitis

Why Probiotics : Low levels of bacterial flora in intestine

 Diverticula - Formation of small bulges / bags in the colon

Diverticulitis Inflammation/ Infection in the diverticula

Mixture of Pre and Probiotic

Probiotics Helps in reducing the PPMs

Prebiotics Helps in Providing food for

Probiotics

Lactobacillus sporogenes

50

million ( Probiotic)

Streptococcus faecalis T-110

30 million (

Prebiotic)

Clostridium butyricum TO-A

2 million

1 million

Prebiotic)

Bacillus mesentericus TO-A

Prebiotic)

Streptococcus faecalis T-110

30 million (

Prebiotic)

Clostridium butyricum TO-A

2 million

1 million

Prebiotic)

Bacillus mesentericus TO-A

Prebiotic)

On ingestion, 3 mutated
live bacteria continue to
proliferate in the GI tract
by a process of
Symbiosis
Symbiosis : Biological
association of two or
more species to their
mutual benefit.