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Antibiotic associated diarrhea (AAD) is a common complication in childhood in the outpatient and inpatient settings. This review provides up to date information on the use of probiotics in the prevention and treatment of AAD, including that from Clostridium Difficile, in children. The most recently systematic reviews and subsequently published randomized controlleds trials are considered. Different single and multistrain probiotics are described; a specific recommendation for the use of Lactobacillus Rhamnosus GG (LGG) and Saccharomyces boulardii (Sb) emerges. New information on LGG survival under amoxicillin/clavulanate therapy in children is also provided. This information is relevant in view of the frequent use of this molecule in children, its association with AAD, and LGG’s sensitivity to penicillin that might make this probiotic ineffective. In spite of a demonstrated positive effect of specific strains of probiotics on AAD, safety issues still remain among which the risk of associated severe infections and of antibiotic resistant gene exchange.

Objectives and study: Recommendations for probiotic use for treatment or prevention in of pediatric intestinal diseases have been produced by scientific societies in several continents, but not in Asia- Pacific region. This paper proposes recommendations for probiotic use for prevention and treatment of gastrointestinal diseases for children living in Asia-Pacific region. Recommendations are based on existing guidelines and on trials conducted in Asia-Pacific countries as well as on considerations of local conditions. Method(s): Target intestinal diseases were identified and their epidemiological and clinical pattern in Asia-Pacific countries were discussed by a panel of experts. Current evidence-based recommendations and guidelines and randomized-controlled trials in the region were revised. Cultural aspects, health management issues, and economic factors were also taken into consideration to formulate recommendations. The strength of each recommendation was rated using the GRADE system. Result(s): The probiotic strains Saccharomyces boulardii CNCM I-745 (Sb) and Lactobacillus rhamnosusGG (LGG) were strongly recommended as active treatment of gastroenteritis in adjunct to oral rehydration. Also Lactobacillus reuteri can be considered. Probiotics may be considered based on evaluation of candidate patients and local setting for the following indications (with the indicated strains): prevention of antibiotic associated diarrhea (LGG or Sb); prevention of Clostridium difficileinduced diarrhea (Sb); prevention of nosocomial diarrhea (LGG); prevention of infantile colics (L reuteri); adjunctive treatment of Helicobacter pylori (Sb and others). Finally probiotics may be considered in infants for prevention of necrotizing enterocolitis but the decision should be left to the physician and discussed with the parents of candidate preterm babies in the light of individual conditions. There is insufficient evidence to formulate recommendations for other gastrointestinal disease

Objectives and study: Recommendations for probiotic use for treatment or prevention in of pediatric intestinal diseases have been produced by scientific societies in several continents, but not in Asia- Pacific region. This paper proposes recommendations for probiotic use for prevention and treatment of gastrointestinal diseases for children living in Asia-Pacific region. Recommendations are based on existing guidelines and on trials conducted in Asia-Pacific countries as well as on considerations of local conditions. Method(s): Target intestinal diseases were identified and their epidemiological and clinical pattern in Asia-Pacific countries were discussed by a panel of experts. Current evidence-based recommendations and guidelines and randomized-controlled trials in the region were revised. Cultural aspects, health management issues, and economic factors were also taken into consideration to formulate recommendations. The strength of each recommendation was rated using the GRADE system. Result(s): The probiotic strains Saccharomyces boulardii CNCM I-745 (Sb) and Lactobacillus rhamnosusGG (LGG) were strongly recommended as active treatment of gastroenteritis in adjunct to oral rehydration. Also Lactobacillus reuteri can be considered. Probiotics may be considered based on evaluation of candidate patients and local setting for the following indications (with the indicated strains): prevention of antibiotic associated diarrhea (LGG or Sb); prevention of Clostridium difficileinduced diarrhea (Sb); prevention of nosocomial diarrhea (LGG); prevention of infantile colics (L reuteri); adjunctive treatment of Helicobacter pylori (Sb and others). Finally probiotics may be considered in infants for prevention of necrotizing enterocolitis but the decision should be left to the physician and discussed with the parents of candidate preterm babies in the light of individual conditions. There is insufficient evidence to formulate recommendations for other gastrointestinal disease

Nosocomial diarrhea may be caused by the use of antibiotics that alter the indigenous microbiota and favor the colonization of pathogens. Clostridium difficile, a Gram positive spore-forming anaerobe, is considered a frequent etiological agent; recently, C. perfringens has also been implicated and may act, synergically with C. difficile. The present study describes the prevalence of these bacteria in a group of children with nosocomial diarrhea, an entity that requires precise therapeutic management. Material and methods. Of the samples of nosocomial diarrheic feces associated to antibiotics from children in a Costa Rican hospital 39 were processed. The presence of toxin A of C. difficile and enterotoxin of C. perfringens was determined. Bacterial isolates were obtained from CCFA and OPSP agar and their antibiotic susceptibility pattern was determined. Results. Enterotoxin of C. perfringens was detected in 3 (7.7%) and C. perfringens was isolated from 8 (20.5%) of the samples, none was enterotoxigenic. All of the isolates were sensitive to nine antibiotics and resistant to four. C. difficile toxin was detected in 6 (15.4%) samples and the bacterium was isolated in 5 (12.8%). None of the isolates was sensitive to cefoxitin, and some presented resistance to other four antibiotics. In 3 (7.7%) of the samples, C. difficile and C. perfringens were simultaneously isolated, but none was positive for both toxins. Discussion. Of the nosocomial diarrheas analyzed 23.1% were caused by C. difficile or C. perfringens, anaerobic pathogens that are not included in Costa Rican hospitals as bacteriological routines. These results reveal the importance of implementing techniques for their detection. The antimicrobial sensitivity tests reveal certain degree of resistance that should be considered for accurate treatment. Further studies shall be performed in order to confirm this resistance., Introducción. La diarrea nosocomial es producida, entre otras causas, por el uso de antibióticos que distorsionan la microbiota indígena y favorecen la colonización de patógenos. Clostridium difficile, una bacteria Gram positiva, anaerobia y esporulada, es considerada agente etiológico frecuente; recientemente se ha implicado a C. perfringens, en ocasiones sinérgicamente con C. difficile. Con este estudio se pretende determinar el papel de estas bacterias en diarreas de niños, población altamente susceptible de infección nosocomial y cuyo manejo terapéutico debe ser cada vez más preciso. Material y Métodos. Se procesaron 39 muestras de diarreas nosocomiales asociadas a antibióticos, de un hospital de niños de Costa Rica. Se determinó la presencia de toxina A de C. difficile y de enterotoxina de C. perfringens. Se realizaron aislamientos bacterianos en agar CCFA y OPSP y se determinó su sensibilidad a los antibióticos. Resultados. Se detectó la enterotoxina de C. perfringens en 3 (7.7%) muestras y se aislaron 8 (20.5%) cepas de C. perfringens, ninguna enterotoxigénica. Todos los aislamientos fueron sensibles a nueve antibióticos y hubo resistencia a otros cuatro. La toxina de C. difficile se detectó en 6 (15.4%) muestras y el aislamiento bacteriano en 5 (12.8%). Ninguno de éstos fue sensible a cefoxitina; hubo resistencia a cuatro antibióticos más. En 3 (7.7%) muestras se aisló C. difficile y C. perfringens, sin detección simultánea de ambas toxinas. Discusión. El 23.1% de las diarreas nosocomiales fueron causadas por C. difficile o C. perfringens, patógenos cuya detección no está incluida en la rutina bacteriológica de los hospitales costarricenses; los resultados demuestran la importancia de implementar técnicas para su detección. Las pruebas de sensibilidad antimicrobiana revelan cierto grado de resistencia, que debería considerarse para brindar un tratamiento adecuado. Es necesario ampliar estos estudios, a fin de corroborar esa resistencia.