Editorial

Old-Fashioned Hand Washing Beats Probiotics Every Day for Preventing C. diff

Almost all gastroenterologists, no matter their expertise, have become quasi-experts in treating patients with Clostridioides difficile infection (CDI) because it is such a common malady, especially in individuals with inflammatory bowel disease (IBD).

The narrative surrounding probiotics for the treatment of CDI holds similar parallels to the probiotic story in IBD, and my colleague, Purna Kashyap, MBBS, said it well.

Conceptually, almost everyone, patients and providers alike, likes the idea of probiotics (“good bacteria”). If we can exploit them, that may constitute a safer way to treat various illnesses. In theory, it is very attractive to try to exploit the body’s resources to prevent or fight infection or inflammation, but the evidence is not all there. The only positive evidence for probiotics for CDI was the meta-analysis which Bradley C. Johnston, PhD, and colleagues conducted, which concluded that there was “moderate quality evidence” that probiotic prophylaxis can safely prevent CDI, especially in patients taking at least two antibiotics and in hospitals with a CDI incidence rate of at least 5%.

Edward V. Loftus Jr.
Edward V.
Loftus Jr.

On the other hand, it’s hard to argue strongly for the use of probiotics, especially because the positive evidence available is not really the highest level of evidence. The best way to answer the ‘Do probiotics have benefit?’ question is to conduct randomized, placebo-controlled trials, and unfortunately those trials are few and far between. Until we see results from those randomized trials proving probiotics to be efficacious, it is always going to be hard to forcefully recommend their use.

A separate issue surrounding probiotics is quality control. Most probiotics are not considered pharmaceuticals, and therefore they are not subject to the same regulations that pharmaceuticals are. For instance, the FDA has the ability to go into a pharmaceutical plant and conduct a random unannounced spot-check at the plant to assess the quality of the product. But the FDA cannot do that for the so-called ‘nutraceuticals’ and so, there’s always the issue of “are people really getting what they think they are getting?”

Whenever patients with IBD ask about probiotics, I take the approach that there’s probably not much downside, but we’re not sure of the upside, and we don’t even know how good that particular probiotic is.

If you’re going to recommend a probiotic, it’s probably better to recommend one where you think the quality control is going to be reasonable (eg, probiotics manufactured by a Fortune 500 company) or one where there’s some evidence of efficacy in at least one gastrointestinal condition.

The best way to prevent CDI is the good old-fashioned practice of vigorous hand washing with warm water and soap. Proper hand washing techniques are the best way to prevent infections, and health care providers are probably one of the “vectors,” so we need to be especially cognizant of that.

– Edward V. Loftus Jr., MD, AGAF, FACG, FACP

Chief Medical Editor

Healio Gastroenterology and Liver Disease

Disclosure: Loftus reports consulting for Janssen, Takeda, AbbVie, UCB Pharma, Amgen, Pfizer, Celgene, Gilead, Eli Lilly, Allergan, Bristol-Myers Squibb, Genentech, and Boehringer Ingelheim; and research support from Janssen, Takeda, AbbVie, UCB Pharma, Amgen, Pfizer, Celgene, Gilead, Robarts Clinical Trials, MedImmune, Genentech, and Seres Therapeutics.

Almost all gastroenterologists, no matter their expertise, have become quasi-experts in treating patients with Clostridioides difficile infection (CDI) because it is such a common malady, especially in individuals with inflammatory bowel disease (IBD).

The narrative surrounding probiotics for the treatment of CDI holds similar parallels to the probiotic story in IBD, and my colleague, Purna Kashyap, MBBS, said it well.

Conceptually, almost everyone, patients and providers alike, likes the idea of probiotics (“good bacteria”). If we can exploit them, that may constitute a safer way to treat various illnesses. In theory, it is very attractive to try to exploit the body’s resources to prevent or fight infection or inflammation, but the evidence is not all there. The only positive evidence for probiotics for CDI was the meta-analysis which Bradley C. Johnston, PhD, and colleagues conducted, which concluded that there was “moderate quality evidence” that probiotic prophylaxis can safely prevent CDI, especially in patients taking at least two antibiotics and in hospitals with a CDI incidence rate of at least 5%.

Edward V. Loftus Jr.
Edward V.
Loftus Jr.

On the other hand, it’s hard to argue strongly for the use of probiotics, especially because the positive evidence available is not really the highest level of evidence. The best way to answer the ‘Do probiotics have benefit?’ question is to conduct randomized, placebo-controlled trials, and unfortunately those trials are few and far between. Until we see results from those randomized trials proving probiotics to be efficacious, it is always going to be hard to forcefully recommend their use.

A separate issue surrounding probiotics is quality control. Most probiotics are not considered pharmaceuticals, and therefore they are not subject to the same regulations that pharmaceuticals are. For instance, the FDA has the ability to go into a pharmaceutical plant and conduct a random unannounced spot-check at the plant to assess the quality of the product. But the FDA cannot do that for the so-called ‘nutraceuticals’ and so, there’s always the issue of “are people really getting what they think they are getting?”

Whenever patients with IBD ask about probiotics, I take the approach that there’s probably not much downside, but we’re not sure of the upside, and we don’t even know how good that particular probiotic is.

If you’re going to recommend a probiotic, it’s probably better to recommend one where you think the quality control is going to be reasonable (eg, probiotics manufactured by a Fortune 500 company) or one where there’s some evidence of efficacy in at least one gastrointestinal condition.

The best way to prevent CDI is the good old-fashioned practice of vigorous hand washing with warm water and soap. Proper hand washing techniques are the best way to prevent infections, and health care providers are probably one of the “vectors,” so we need to be especially cognizant of that.

– Edward V. Loftus Jr., MD, AGAF, FACG, FACP

Chief Medical Editor

Healio Gastroenterology and Liver Disease

Disclosure: Loftus reports consulting for Janssen, Takeda, AbbVie, UCB Pharma, Amgen, Pfizer, Celgene, Gilead, Eli Lilly, Allergan, Bristol-Myers Squibb, Genentech, and Boehringer Ingelheim; and research support from Janssen, Takeda, AbbVie, UCB Pharma, Amgen, Pfizer, Celgene, Gilead, Robarts Clinical Trials, MedImmune, Genentech, and Seres Therapeutics.