Acidophilus; Saccaromyces boulardii|
Alteration of intestinal microflora is a common side effect of antibiotic
treatment (Nord 1993; Beaugerie 1996). Azithromycin significantly reduces
bifidobacteria levels in healthy individuals (Uchino et al. 1995) and increases
the incidence of antibiotic-induced diarrhea in some patients (Gorenek et al.
1999). Clarithromycin suppresses the growth of both bifidobacteria and
lactobacillus bacteria in healthy subjects (Edlund et al. 2000). Erythromycin
also significantly alters intestinal microflora after oral administration
(Brismar et al. 1991; Nord et al. 1986). In vitro, erythyromycin strongly
inhibits various strains of bifidobacteria (Lim et al. 1993). These changes can
affect the availability of vitamins B and K.
Altering the balance of probiotic organisms in the gastrointestinal tract may
reduce resistance to infection and disease. Symptoms of deficiency include gas,
abdominal distress, diarrhea, and yeast infections (Galland
Prophylactic administration of a combination of L. acidophilus and
L. bulgaricus prevents ampicillin-induced diarrhea (Gotz et al. 1979).
Other bacterial strains that may prevent or treat antibiotic-induced diarrhea
include L. casei GG, Saccaromyces boulardii, and
Bifidobacterium longum (either alone or combined with L.
acidophilus) (Elmer et al. 1996). Administration of preparations containing
1 to 2 billion organisms are typically required (Murray and Pizzorno 1998).
Positive results have been observed with S. boulardii at doses of 250 mg
bid (Surawicz et al. 1989) or 1 g/day containing 3 x 1010
colony-forming units (the equivalent of 2 x 250 mg capsules bid) (McFarland et
Vitamin B9 (Folic
Intestinal bacteria synthesize vitamin K and B vitamins such as biotin, B2,
B12, and folic acid; they are a potentially rich source of these nutrients
(Albert et al. 1980; Hill 1997). Although it is unusual to see measurable
deficiencies, chronic antibiotic therapy could deplete these vitamins by
altering and destroying the normal intestinal bacteria that synthesize them
Vitamin B2: Riboflavin deficiency usually occurs as a result of
deficiencies in dietary protein and is associated with other B vitamin
deficiencies (Covington 1999). Depleted levels of riboflavin affect carbohydrate
and amino acid metabolism by interfering with enzyme systems involved in the
production of ATP. Lack of an adequate supply of riboflavin disturbs several
physiological and biochemical processes and results in retarded growth in
infants and children (Covington 1999; Powers 1999). Symptoms include corneal
vascularization, glossitis, cheilosis, seborrheic dermatitis, and impaired wound
healing (Covington 1999).
Vitamin B9: Low levels of folate have been linked to colon cancer,
heart disease, cognitive deficits, and birth defects, specifically neural tube
defects (Ames 2000; Covington 1999). Deficiency increases chromosome breakage
and elevates serum homocysteine. Vitamin B9 deficiency may also lead to
Vitamin B12: Symptomatic vitamin B12 deficiency is rare because
complications may appear only after the deficiency has existed for 10 to 15
years (Berger 1985; Carpentier et al. 1976). Low vitamin B12 levels could
increase the risk of colon cancer, heart disease, brain dysfunction, birth
defects, and irreversible neuropathy (Ames 2000; Covington 1999). Irritability,
weakness, numbness, fatigue, glossitis, anorexia, headache, palpitations, and
altered mental status, including personality and behavioral changes, are some of
the signs and symptoms of vitamin B12 depletion (Covington 1999). Prolonged
deficiency leads to pernicious or megaloblastic anemia that may be associated
with leukopenia and thrombocytopenia.
Vitamin H: Although biotin deficiency is uncommon, nonspecific
symptoms such as changes in skin color as well as the development of
non-pruritic dermatitis, alopecia, and muscle pain may be indicative of depleted
biotin levels (Covington 1999). Additionally, low levels of this nutrient may be
associated with hypercholesterolemia, anemia, anorexia, depression, and
Note: B vitamins are best if given as B-complex.
Vitamin B2: Doses of 5 to 25 mg/day are recommended for the treatment
of riboflavin deficiency (Covington 1999). For replacement therapy, doses should
be based upon the patient's individual needs, considering the clinical
presentation, serum riboflavin levels, age, gender, dietary habits, and
Vitamin B9: The recommended dietary allowance (RDA) for adults
is 300 to 600 mcg/day (Covington 1999). However, recommendations of doses of
folic acid as high as 2000 mcg/day have been reported in the literature (Mayer
et al. 1996). For replacement therapy, doses should be based upon the patient's
individual needs, considering the clinical presentation, serum folate levels,
age, gender, dietary habits, and medication regimen.
Vitamin B12: Doses of 25 to 250 mcg/day of vitamin B12 have
been used to correct nutritional deficiency (Covington 1999). Oral doses between
500 to 1000 mcg/day have been recommended for the treatment of pernicious anemia
(Carmel 2000). Replacement therapy should be based on the patient's individual
needs, considering the clinical presentation, serum B12 levels, age, gender,
dietary habits, and medication regimen.
Vitamin H: Biotin deficiency is treated with doses between 1 mg and 10
mg to resolve symptoms and prevent recurrence (Mock et al. 1996). Replacement
therapy should be based upon the patient's clinical presentation, serum biotin
levels, age, gender, dietary habits, and medication
Broad spectrum antibiotics reduce hepatic vitamin K2 (menaquinone) stores as
well as gut microflora, which can deplete vitamin K by diminishing bacterial
synthesis of this nutrient (Conly and Stein 1994; Stieger et al. 1992).
Interference with intestinal synthesis of vitamin K is usually not sufficient
to cause a deficiency (Covington 1999). However, a reduction in prothrombin and
other vitamin K-dependent factors may indicate a deficiency (Olson 1999). Severe
deficiency may be associated with detectable plasma levels of
descarboxyprothrombin (Vermeer and Schurgers 2000). Signs and symptoms of
deficiency include coagulation disorders manifested by hypoprothrombinemia with
internal and external hemorrhage (Covington 1999).
Generally, 45 to 80 mcg/day are recommended for daily intake to maintain
overall health (Covington 1999). Individual requirements should be tailored to
the patient's clinical presentation, serum levels, age, gender, dietary habits,
and medication regimen.
This information is intended to serve as a concise reference for healthcare
professionals to identify substances that may be depleted by many commonly
prescribed medications. Depletion of these substances depends upon a number of
factors including medical history, lifestyle, dietary habits, and duration of
treatment with a particular medication. The signs and symptoms associated with
deficiency may be nonspecific and could be indicative of clinical conditions
other than deficiency. The material presented in these monographs should not in
any event be construed as specific instructions for individual
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intestinal bacteria. Nature. 1980;283(5749):781-782.
Ames BN. Micronutrient deficiencies: A major cause of DNA damage. Ann NY
Acad Sci. 2000;889:87-106.
Beaugerie L. [Diarrhea caused by antibiotic therapy]. Rev Prat.
Berger W. Incidence of severe side effects during therapy with sulfonylureas
and biguanides. Horm Metab Res Suppl. 1985;15:111-115.
Brismar B, Edlund C, Nord CE, et al. Comparative effects of clarithromycin
and erythromycin on the normal intestinal microflora. Scand J Infect Dis.
Carmel R. Current concepts in cobalamin deficiency. Ann Rev Med.
Carpentier JL, Bury J, Luyckx A, Lefebvre P. Vitamin B12 and folic acid serum
levels in diabetics under various therapeutic regimens. Diabetes Metab.
Conly J, Stein K. Reduction of vitamin K2 concentrations in human liver
associated with the use of broad spectrum antimicrobials. Clin Invest
Covington T, ed. Nonprescription Drug Therapy Guiding Patient
Self-Care. St Louis, MO: Facts and Comparisons; 1999:467-545.
Edlund C, Beyer G, Hiemer-Bau M, et al. Comparative effects of moxifloxacin
and clarithromycin on the normal intestinal microflora. Scand J Infect
Elmer GW, Surawicz CM, McFarland LV. Biotherapeutic agents. A neglected
modality for the treatment and prevention of selected intestinal and vaginal
infections. JAMA. 1996;275(11):870-876.
Galland L. The Four Pillars of Healing. New York, NY: Random House;
Gorenek L, Dizer U, Besirbellioglu B, et al. The diagnosis and treatment of
clostridium difficile in antibiotic-associated diarrhea.
Gotz V, Romankiewicz JA, Moss J, Murray HW. Prophylaxis against ampicillin
associated diarrhea with a lactobacillus preparation. Am J Hosp Pharm.
Hill MJ. Intestinal flora and endogenous vitamin synthesis. Eur J Cancer
Prev. 1997;6(Suppl 1):S43-45.
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Dairy Sci. 1993;76(8):2168-2174.
Mayer EL, Jacobsen DW, Robinson K. Homocysteine and coronary atherosclerosis.
J Am Coll Cardiol. 1996;27(3):517-527.
McFarland LV, Surawicz CM, Greenberg RN, et al. Prevention of
Beta-lactam-associated diarrhea by Saccharomyces boulardi compared with
placebo. Am J Gastroenterol. 1995;90(3):439-448.
Mock DM. Biotin. In: Ziegler EE, Filer LJ, eds. Present Knowledge in
Nutrition. 7th ed. Washington, DC: ILSI Press; 1996:231.
Murray M, Pizzorno J. Encyclopedia of Natural Medicine 2nd
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intestinal microflora. Vet Microbiol. 1993;35(3-4):193-197.
Nord CE, Heimdahl A, Kager L. Antimicrobial induced alterations of the human
oropharyngeal and intestinal microflora. Scand J Infect Dis Suppl.
Olson RE. Vitamin K. In: Shils, ME, Olson JA, Shike, M, eds. Modern
Nutrition in health and disease. 9th ed. Media, PA: Williams & Wilkins;
Powers HJ. Current knowledge concerning optimum nutritional status of
riboflavin, niacin and pyridoxine. Proc Nutr Soc. 1999;58(2):435-440.
Stieger R, Baumgartner K, Neff U. [Dangerous hypothrombinemic hemorrhage in
antibiotic therapy]. Helv Chir Acta. 1992;58(6):775-778.
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diarrhea by Saccharomyces boulardii: A prospecive study.
Uchino U, Kanayama A, Hasegawa M, et al. [Effects of azithromycin on fecal
flora of healthy adult volunteers]. Jpn J Antibio.
Vermeer C, Schurgers LJ. A comprehensive review of vitamin K and vitamin K
antagonists. Hematol Oncol Clin North Am.
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