That has turned people around to think about the possibility of using probiotics to see if we could somehow affect the gut flora in a, I suppose, in a more positive way, as opposed to just an anti-way with the antibiotic. The bacteria that are used are typically referred to as "good" bacteria. Bad bacteria, or the most evil bacteria, I suppose, would be pathogens such as salmonella, Campylobacter, etc., that produce disease, obviously.

Probiotics primarily consist of good bacteria, such as lactobacillus, bifidobacteria, streptococcus, that in the gut are thought to exert a more positive effect on gut health.

The interest in using these in inflammatory bowel disease has grown immensely over the last several years, primarily fueled by very few clinical studies that have shown quite promising results in a limited number of patients. These agents that have shown efficacy in studies, in general, have been very carefully formulated, require a fairly high dose of probiotic in regimens that are usually somewhat complex in terms of the amount of powder that one must take in a given day.

The thing that's lacking at this point in probiotic therapy in inflammatory bowel disease is a standardized cocktail, a standardized soup of bugs that can be used to treat inflammatory bowel disease. The second thing that's missing is a standardized form of delivery. As we know, most bacteria are eliminated simply by passing through the harsh environment of the stomach. So the delivery systems need to be more standardized. And that I think really sums up the two main roadblocks at this point to not only accomplishing good clinical trials, but actually disseminating them-should they be effective-to the patients who really need them.

My advice to doctors who are taking care of patients who are taking these agents-and almost all of the patients are-is to be wary and be skeptical. Most of the probiotic agents that are available in a typical health food store are probably not containing either the bacterial count or even anything that's on their label. Remember, these are foods, these are not drugs, they are not being carefully evaluated or examined or monitored by any agency. The FDA has nothing to do with these, even though we're using them as therapies. So be very, very skeptical.

There are some probiotic companies that I think are very aggressively promoting themselves. There are others that are simply doing the work that needs to be done, which is doing the trials. One agent, VSL #3, that has been out there carefully studying these claims of the probiotics, I think is a good example of a good probiotic company citizen. However, I would say the bulk of the others, I'd be wary of.

The second thing I'd be aware of that if you do find a formulation that is what it says it is, that you should err on the side of getting an appropriate dose and make sure you know what it is you're treating. For example, there is some data that shows that probiotics work for pouchitis that's responded to antibiotic therapy. That's a fairly limited indication and when you use it, follow the patient and use the same standards of judging whether or not a therapy works with a probiotic that you would use with any other agent; again, looking for intolerance, side events, side effects and the like.

I think the general consensus on these agents is that they're harmless or they don't have side effects. And I think the studies haven't been done in sufficient numbers for people to feel confident about those types of claims.