Treating the runs
This yeast strain was isolated from mangosteen and lychee peels that were part of a traditional remedy for diarrhoea in Indochina.
WE all know that feeling: the sharp pain in the tummy, the mad dash to the toilet as the need to answer nature’s call overwhelms everything else, the hot gush of liquid faeces exiting the body, the lassitude that leaves no energy for other activities – there’s no doubt that acute diarrhoea is a pain in the butt, both literally and metaphorically.
While for adults, this common condition is more often than not an annoyance, rather than anything serious, acute diarrhoea can be quite deadly in the very young.
According to Universiti Kebangsaan Malaysia associate professor Dr Raja Affendi Raja Ali, around 1.8 million people die from diseases due to diarrhoea around the world every year.
Ninety percent of them are children aged below five, who mostly live in developing countries.
The consultant gastroenterologist notes that a 2011 paper published in the Journal of Health Population and Nutrition, and derived from the 2006 National Health and Morbidity Survey (NHMS), concluded that acute diarrhoea is still a major public health problem in Malaysia.
“The baseline incidence and distribution of acute diarrhoea among the general population is high – 5%.
“There is a total of 13.5 million episodes of acute diarrhoea a year, and these mostly affect teenagers, young adults and children,” he says.
“You can imagine, in clinical practice, diarrhoea is everyday business. In the emergency department, patients of all ages present with acute diarrhoea,” he adds.
Acute diarrhoea is defined as three or more episodes of loose stools, or decreased stool consistency, in any 24-hour period within the past two to four weeks.
What causes diarrhoea
There are a number of causes for this condition, but the most common one by far – causing 90% of cases – are infections of the gut, or acute gastroenteritis, typically caused by food poisoning.
The most common infective microorganism for children is the rota virus, says Assoc Prof Raja Affendi.
Other microorganisms that can cause acute gastroenteritis are bacteria like Escherichia coli and Clostridium difficile, and protozoa like Giardia lamblia and Entamoeba histolytica.
Other causes of acute diarrhoea include inflammatory bowel disease, irritable bowel syndrome, colon cancer and “more importantly nowadays, the emerging increase in antibiotic-associated diarrhoea”, he adds.
According to senior consultant paediatric gastroenterologist Prof Dr Quak Seng Hock, diarrhoea constitutes around 7% of adverse drug reactions, or side effects, from antibiotics.
“Many, many drugs can cause diarrhoea,” says the National University Hospital, Singapore, Division of Gastroenterology and Hepatology head.
“Ten to twenty percent of these reactions are caused by antibiotics – this is a side effect or change in the microflora of our intestines.”
He explains: “Most of the antibiotics producing diarrhoea are usually what we call broad-spectrum antibiotics.
“Broad-spectrum antibiotics means that they cover (i.e. kill) a lot of germs.
“So when they cover a lot of germs, they are useful when we don’t know what the germ causing the infection is.”
Because these broad-spectrum antibiotics kill off most of the microorganisms in the gut, including the good ones, it causes an imbalance in the gut’s ecosystem, making it easy for disease to set in, says Assoc Prof Raja Affendi.
Diarrhoea is actually the body’s effort to evict these harmful microorganisms and toxins.
Explains Prof Quak: “Our body’s tendency is to repair any injury.
“Suppose we cut ourselves, if we don’t do anything, it will heal by itself.
“Any infection is also the same – it will heal by itself.
“Diarrhoea is actually a physiological process where our body tries to get rid of whatever ‘dirt’ or germs in our body.”
Supportive treatment
As the cause of the vast majority of cases of acute diarrhoea are viruses, the treatment is usually only supportive.
Says Assoc Prof Raja Affendi: “We encourage patients to take as much fluid as possible to prevent dehydration.
“We also ask patients to take oral rehydration drinks to replace the salts and minerals they might lose.
“And in severe cases, patients may need to be admitted for intravenous fluid supplement, because otherwise, they will get low blood pressure, which can cause a lot of consequences.
“In fact, in children and the elderly, it can cause severe health issues leading to death.”
He adds that medications prescribed are usually to treat nausea, diarrhoea and any underlying disease. Antibiotics are not usually given, as most cases of acute diarrhoea are caused by viruses.
In addition, probiotics are part of the World Gastroenterology Organisation’s (WGO) treatment guidelines for acute gastroenteritis in both adults and children.
Probiotics, as defined by the World Health Organisation, are live microorganisms that, when administered in adequate amounts, confer a health benefit on the host. They can be either bacteria or yeast.
Prof Quak notes that yeast consists of less than 1% of microorganisms in the body.
He says that the important difference between yeast and bacteria probiotics is that bacteria can exchange genetic information among themselves, including those conferring antibiotic resistance, which is far less likely to occur between yeast and bacteria.
“So it is safer to use yeast in terms of antibiotic utilisation,” he says.
He adds that a number of studies have shown that using the yeast strain Saccharomyces boulardii CNCM I-745 decreases the duration of diarrhoea by an average of one day.
If you think that one day is nothing, Prof Quak says: “Do not dismiss one day as insignificant.
“If you are having diarrhoea, (think of ) how uncomfortable you are – a day is significant.
“Not to mention for children, parents have to take leave from work.
“And in children, a day of diarrhoea can be very debilitating, because when you have diarrhoea, you can’t eat, you can’t digest, so you’re not only not consuming the energy required, but you’re also losing energy due to the illness.”
Going hand-in-hand
In addition, Prof Quak quoted a 2015 study in the journal
Alimentary Pharmacology & Therapeutics that found that S. boulardii CNCM I-745 was effective in reducing antibiotic-associated diarrhoea by 53%, with 8.5% of those taken the probiotic experiencing diarrhoea compared to 18.7% of those who did not take it.
“It doesn’t stop all the diarrhoea altogether, but the chances of having diarrhoea is decreased by half,” he says.
He also zeroed in on C. difficile, which he says is difficult to treat.
“This is a harmful organism found in the gut. If you use a lot of antibiotics, it kills off all the germs, but this organism flourishes, so instead of the patient getting better, they get diarrhoea,” he explains.
However, a 1994 study in the
Journal of the American Medical Association ( JAMA) showed that when taken together with an antibiotic, S. boulardii CNCM I-745 reduced the incidence of diarrhoea in C. difficile infections by 41%, from 44.8% in those who took a placebo with the antibiotic, to 26.3% in those who took the probiotic and antibiotic.
He concludes that: “The use of S. boulardii CNCM I-745 as a therapeutic probiotic is evidence-based for both efficacy and safety for several types of diarrhoea, among them, acute diarrhoea, antibiotic-associated diarrhoea, C. difficile diarrhoea and traveller’s diarrhoea.
“It is good for the reduction of the duration and severity of diarrhoea – it doesn’t stop diarrhoea altogether.
“It’s also good for preventing certain types of diarrhoea – it doesn’t prevent altogether, but the risk is less.”
Both Prof Quak and Assoc Prof Raja Affendi were speaking at the recent launch of Bioflor (KKLIU: 0817/2018), the first yeast probiotic available in Malaysia.
According to Servier Malaysia product manager Dr Alan Wong, Bioflor – which contains S. boulardii CNCM I-745 – is registered as a medicinal-grade probiotic and is available over-the-counter in pharmacies.
It is approved in Malaysia for the treatment of acute diarrhoea in adults and children; and the prevention of both antibiotic-associated diarrhoea and recurrent diarrhoea due to C. difficile in combination with the antibiotics vancomycin and metronidazole.
Other countries have also approved it for the prevention of traveller’s diarrhoea and diarrhoea associated with enteral nutrition, treatment of AIDS-associated diarrhoea, and as adjuvant therapy for irritable bowel syndrome.
It is produced by the French pharmaceutical company Biocodex and distributed in Malaysia by Servier.