Objective To assess the clinical efficacy of Lactobacillus sporogenes (Bacillus coagulans), as probiotic preparation, against dehydrating diarrhoea in children.
Methods Double-blind, randomised, placebo-controlled, hospital-based clinical trial with children aged 6–24 months who had diarrhoea with some dehydration. Children received tablets of L. sporogenes (B. coagulans) or placebo (control group) and oral rehydration salt solution for correction of initial dehydration as well as maintenance therapy. Duration, frequency, volume of diarrhoea and intake of ORS of two groups were compared as outcome variables.
Results One hundred and forty-eight children participated, of whom 78 (Study group) received L. sporogenes (B. coagulans) and 70 received placebo (Control group). Differences in recovery rate (P = 0.2), duration (P = 0.5), frequency (P = 0.05), volume (P = 0.1) of diarrhoea, intake of ORS (P = 0.2) and other fluids (P = 0.1) were not significant between both groups. Neither did a subgroup analysis of children who had rotavirus as sole enteropathogens show any significant differences in duration (P = 0.5), frequency (P = 0.6), volume (P = 0.8) of diarrhoea, intake of ORS (P = 0.8) and other fluids (P = 0.8) among both groups.
Conclusion L. sporogenes (B. coagulans), as an adjunct to ORS, had no therapeutic impact on management of acute dehydrating diarrhoea of diverse etiology including rotavirus associated diarrhoea in children.
Essai clinique randomisé contrôlé de l’utilisation de Lactobacillus sporogenes (Bacillus coagulans), comme probiotiques dans la pratique clinique, sur la diarrhée aiguë aqueuse chez les enfants
Objectif: Evaluer l’efficacité clinique de Lactobacillus sporogenes (coagulans Bacillus), comme préparation probiotique contre la diarrhée déshydratante chez les enfants.
Méthodes: Essai clinique en double aveugle, randomisé, contrôlé versus placebo, en milieu hospitalier sur des enfants de 6 à 24 mois ayant une diarrhée avec déshydratation. Les enfants ont reçu des comprimés de Lactobacillus sporogenes (Bacillus coagulans) ou un placebo (groupe témoin) et une solution de sels de réhydratation orale (SRO) pour la correction de la déshydratation initiale ainsi que comme traitement d’entretien. La durée, la fréquence, le volume de la diarrhée et la prise de SRO dans les deux groupes ont été comparés en tant que variables de résultat.
Résultats: 148 enfants ont participé, dont 78 (groupe d’étude) ont reçu Lactobacillus sporogenes (Bacillus coagulans) et 70 ont reçu un placebo (groupe témoins). Les différences dans les taux de récupération (P = 0.2), la durée (P = 0.5), la fréquence (P = 0.05), le volume (P = 0.1) de la diarrhée, la prise de SRO (P = 0.2) et d’autres fluides (P = 0.1) n’étaient pas significatives entre les deux groupes. Une analyse de sous-groupe d’enfants qui avaient le rotavirus comme seul entéropathogène n’a pas non plus montré de différences significatives dans la durée (P = 0.5), la fréquence (P = 0.6), le volume (P = 0.8) de la diarrhée, la prise de SRO (P = 0.8) et d’autres fluides (P = 0.8) entre les deux groupes.
Conclusions: Lactobacillus sporogenes (Bacillus coagulans), comme un complément aux SRO, n’a aucun impact sur la prise en charge thérapeutique de la diarrhée aiguë avec déshydratation d’étiologie diverse y compris la diarrhée associée à rotavirus chez les enfants.
Ensayo clínico aleatorizado y controlado utilizando en la práctica clínica al Lactobacillus sporogenes (Bacillus coagulans) como probiótico para niños con diarrea aguda líquida
Objetivo: Evaluar la eficacia clínica de Lactobacillus sporogenes (Bacillus coagulans), como preparado probiótico, frente a la diarrea líquida aguda en niños.
Métodos: Ensayo clínico hospitalario, doble ciego, aleatorizado, controlado con placebo, con niños con edades comprendidas entre los 6–24 meses que tuvieron diarrea y algo de deshidratación. Los niños recibieron tabletas de Lactobacillus sporogenes (Bacillus coagulans) o placebo (grupo control), y solución de sales de rehidratación oral para corregir la deshidratación inicial, al igual que terapia de mantenimiento. La duración, frecuencia, volumen de diarrea e ingestión de sales de rehidratación oral (SRO) de los dos grupos fueron comparadas como variables de resultados.
Resultados: Participaron 148 niños, de los cuales 78 (grupo de estudio) recibieron Lactobacillus sporogenes (Bacillus coagulans) y 70 recibieron placebo (grupo Control). Las diferencias en la tasa de recuperación (P = 0.2), duración (P = 0.5), frecuencia (P = 0.05), volumen (P = 0.1) de la diarrea, ingestión de SRO (P = 0.2) y otros líquidos (P = 0.1) no eran significativas entre ambos grupos. Tampoco se observaron diferencias significativas en la duración (P = 0.5), frecuencia (P = 0.6), volumen (P = 0.8) de la diarrea, ingesta de SRO (P = 0.8) y otros fluidos (P = 0.8) entre ambos grupos en un análisis del subgrupo de niños que tenían rotavirus como único enteropatógeno.
Conclusiones: Lactobacillus sporogenes (Bacillus coagulans), acompañado con SRO, no tenía un impacto terapéutico en el manejo de la diarrea aguda deshidratante en niños, con diversas etiologías incluyendo la diarrea por rotavirus.
Diarrhoeal diseases continue to be a major cause of morbidity and mortality in developing countries (WHO 2008). Reduced osmolarity oral rehydration salt solution (ORS) and zinc supplementation bear a great potential for better management of diarrhoea (WHO 2006). Recently probiotics therapy, evidenced by numerous randomised clinical trials (RCTs) followed by meta analyses and Cochran reviews, has attended a great deal of renewed interest, due to its significant therapeutic effect on rotavirus-associated diarrhoea in children in developed countries (Saavedra et al. 1994; Szajewska et al. 2000; Huang et al. 2002; Van Niel et al. 2002; Isolauri 2003; Reid et al. 2003; Allen et al. 2004; Szajewska et al. 2006). The most commonly used strains of probiotics belong to the genera Lactobacillus and Bifidobacterium, but other microorganisms including Enterococcus, Streptococcus, Escherichia coli and Saccharomyces species have also been used.
Community based studies also documented reduction in incidence of acute diarrhoea with various levels of significance by using Lactobacillus casei and Lactobacillus rhamnosus GG (Oberhelman et al. 1999; Sur et al. 2010). Sazawal et al. (2006) conducted systematic review of 34 masked, randomised, placebo controlled trials to evaluate the efficacy of probiotics in prevention of acute diarrhoea. Probiotics significantly reduced the risk of diarrhoea developing in infants and children by 57% (confidence interval, 35–71%). Canani et al. (2007) compared the efficacy of five probiotic preparations in a community based study for the treatment of acute diarrhoea in children with L. rhamnosus GG, Saccharomyces boulardii, Bacillus clausii, mix of L. delbrueckii var bulgaricus, Streptococcus thermophilus, L. acidophilus, and Bifidobacterium bifidum or Enterococcus faecium SF 68. Median duration of diarrhoea was significantly shorter and frequency was lower only in those children who received L. rhamnosus GG and a mix of four bacterial strains. This community-based study indicated that not all commercially available probiotic preparations were effective for the treatment of diarrhoea in children.
Some of the probiotic preparations of Lactobacillus and Streptococcus species showed inconsistent results in RCTs among Indian children, used singly or in combination, for the treatment of diarrhoea (Khanna et al. 2005; Basu et al. 2007, 2009; Dubey et al. 2008). Lactobacillus sporogenes (Bacillus coagulans) is one of the most commonly available and marketed probiotic preparations in many European and Asian countries, including India (Sanders et al. 2003; Vecchi & Drago 2006), but the efficacy of this preparation on the management of diarrhoea was not evaluated by RCT. Rather, the role of this bacterium as probiotic is based on few small numbered studies (Mohan et al. 1990a,b; La Rosa et al. 2003).
We conducted a randomised, double blind, placebo controlled clinical trial to test the hypothesis that probiotic therapy with Lactobacillus sporogens (B. coagulans), as an adjunct of oral rehydration salt solution (ORS), should have better therapeutic impact on management of acute dehydrating diarrhoea including rotavirus-associated diarrhoea in children. Duration, frequency, volume of diarrhoea and intake of ORS of study and control groups were compared as outcome variables.
Patients and methods
This double-blind, randomised, placebo-controlled, hospital-based clinical trial was conducted at Dr. B.C. Roy Memorial Hospital for Children, Kolkata, India between September 2003 and July 2005. Boys (for ease of collection of stool and urine separately), aged between 6 and 24 months, who suffered from dehydrating acute watery diarrhoea of less than 3 days’ duration and had clinical signs and symptoms of ‘some’ dehydration (thirst or eagerness to drink, sunken eyes, dry mouth and tongue and loss of skin elasticity) were assessed for eligibility (WHO 2006). Children were excluded from the study if they (i) had a history of an episode of diarrhoea within one month of the present illness to exclude recurrent and persistent diarrhoea; (ii) were exclusively breast fed; (iii) had severe dehydration; (iv) had diarrhoea associated with another systemic illness (e.g. septicaemia, pneumonia, urinary tract infection, otitis media) or chronic underlying diseases (e.g. tuberculosis, liver diseases); (v) had severe malnutrition; (vi) needed extensive care (e.g. life support system, blood transfusion or total parental nutrition); (vii) had received an antibiotic before enrolment. Children of parents who provided informed written consent after explaining the details of the study procedure were enrolled. Children were screened by trained doctors at the Diarrhea Treatment and Training Unit of Dr. B.C Roy Memorial Hospital for Children and admitted to the study ward for subsequent procedures by doctors and nurses who were involved in the study.
This project was approved by the Scientific Advisory Committee and the Institutional Ethics Committee of National Institute of Cholera and Enteric Diseases, Kolkata, India. After enrolment, a complete history was taken from the parents and a thorough physical examination conducted. Findings were recorded in predesigned clinical research forms (CRF). Stool samples were collected in sterile MacCartney’s bottles using sterile rectal catheter and were processed for detection of established enteric pathogens including bacteria, viruses and parasites using standard techniques (WHO 1983). Children were weighed unclothed on admission using a weighing balance of 1 g precision. Length and mid-arm circumference of the children were also recorded.
The children were allocated the study drug or placebo tablets from a specific numbered blister foil following a computer-generated random number table. The random number table was held by a person not associated with the study, who was also responsible for providing 20 tablets (10 tablets in each foil) according to the random number table, keeping the serial code numbers in a sealed envelope and identifying the groups after completion of the study. Each dispersible tablet contained 60 million spores of L. sporogenes (B. coagulans) or placebo. Two tablets were administered orally by dispersing in 15 ml of water two times a day until recovery or for 5 days, if not recovered before that period (a total daily dose of 240 million spores) according to the general guidelines (Badmaev & Majeed 1999) and manufacturers’ instruction.
The dispersible tablets of L. sporogenes (B. coagulans) and placebo were identical in colour, shape, size and test and were prepared by M/S ESKAG Pharma Private Limited, Kolkata, India for this study. The study drug was standardised by the manufacturer and supplied in batches. The viable level of the study product was expected to remain unchanged at the prevailing storage condition of room temperature (Adami & Cavazzoni 1993) and also indicated by the manufacturer.
All the patients received reduced osmolar oral rehydration salt solution as recommended by WHO for correction of initial dehydration. After correction of initial dehydration, children continued to receive the solution as maintenance therapy matching the stool volume and loss in vomitus until the diarrhoea ceased (WHO 2006). However, more fluid was given if the child wanted it and if there were clinical indications. We also planned to add intravenous fluid (Ringer’s lactate solution) if patient developed ‘severe’ dehydration or intractable vomiting during hospital stay as per guidelines of WHO (WHO 2006). Patients were offered plain water ad libitum. Breast-fed children were allowed to continue breast feeding. Formula or animal milk or normal diet was also permitted. Children did not receive any antibiotic, anti diarrhoeal or anti emetic drug during the study period. Children who developed complications during the study period were withdrawn and treated according to the treatment protocol of the hospital. Children were also withdrawn from the study if the parents were unwilling to continue the study procedure. The final study population was constituted by children who continued the study procedure until recovery or to day 5 of therapy.
Patients were weighed after correction of initial dehydration and every morning until recovery or for 5 days if not recovered before that period. Intake and output charts were updated every 8 h until recovery or for 5 days if the illness persisted. Amounts of fluid intake (ORS, plain water, other liquid food and I.V. fluid if needed) were also measured. Stool was measured after collection in pre-weighed diapers with an accuracy of 1 g. Urine was separated from stool using urine collection bags. Loss due to vomiting was evaluated by weighing pre weighed gauze pads. Patients were discharged from hospital when they fulfilled the recovery criteria (recovery was defined as passage of soft stool or normal stool or no stool for last 18 h), even before 5 days. The period between initiation of therapy and passage of the last liquid stool was considered as duration of diarrhoea. Prescribed tablets were supplied to the parents to continue for 5 days. Parents were advised of a compulsory follow up visit on day 15 after discharge, or any time in between if the child developed any complication or adverse event.
Sample size calculation
The sample size was calculated with the assumption that the average duration of diarrhoea in study groups would be 25% less than the mean duration of 66.4 h (±32.3) after initiation of standard treatment (Dutta et al. 2001). Considering 5% level of significance, 80% power and 10% loss of follow up (dropout), minimum sample size was calculated as 42 children in each of two groups. However, we doubled the number of children (80 in each group) as we planned to add a subgroup population who suffered from diarrhoea with rotavirus as sole pathogen to detect the trend of reduction of outcome variables.
Data were entered in PC for analysing the trial result; a checklist of treatment assignment was collected for decoding the experimental groups. Two study groups were compared based on the clinical characteristics on admission and isolation of enteropathogens by chi-squared test. The means of outcome variables were compared by using Student’s t-test.
A total of 182 boys suffering from dehydrating acute diarrhoea with ‘some’ dehydration were assessed for eligibility. Twenty-two children were excluded because the parents declined participation. One hundred and sixty children received either the study drug or placebo from the numbered foil pack in a double blind manner. On day 1 of the study procedure, 12 children discontinued the intervention due to unwillingness of the parents. Thus 148 children who continued the study procedure until recovery or up to day 5 of therapy constituted the study population (Figure 1).
After completion of the study and entering the data in the computer the products received by the two groups were identified. Seventy-eight children had received L. sporogenes (B. coagulans) and 70 had received placebo (control group). The difference in the number of children in each group was not statistically significant. As the baseline features of study population shown in Table 1 demonstrate, the groups were comparable. Enteropathogens detected at the time of enrolment were also similar in the groups (Table 2). Seventy (89.7%) children in the study group and 58 (82.9%) in the control group recovered within 5 days of hospitalisation (Table 3); this difference in recovery rate was not statistically significant (P = 0.2). Differences in mean values of duration of diarrhoea (P = 0.5), frequency of stool (P = 0.05), stool output (P = 0.1), ORS intake (P = 0.2) and intake of other fluids (P = 0.1) were not significant between groups.
Table 1. Characteristics on enrolment
Study group (n = 78)
Control group (n = 70)
Results expressed in mean (±SD).
All children in both groups had ‘some’ dehydration.
12 ± 4
11 ± 4
Body weight (g)
7861 ± 1441
7491 ± 1488
70.7 ± 5.7
69.7 ± 6.1
Mid arm circumference (cm)
13.5 ± 1.1
13.4 ± 1.2
Frequency of stool/day
9 ± 4
11 ± 4
Table 2. Detection of enteropathogens on enrolment
Study group (n = 78)
Control group (n = 70)
Results expressed in number (%).
V. cholerae O1
V. cholerae non-O1, non-O139
Un classified E. coli
Table 3. Outcome variables of children irrespective of etiological agents
Study group (n = 78)
Control group (n = 70)
Results expressed in mean (±SD) unless otherwise indicated.
Cure (no, %)
Duration of diarrhoea (h)
34.0 ± 20.4
36.5 ± 21.4
Stool output (g)
742.3 ± 575.4
905.7 ± 622.4
Frequency of stool (no)
10.8 ± 8.3
14.1 ± 10.3
ORS intake (ml)
1487.7 ± 675.2
1634.6 ± 783.4
Liquid + plain water (ml)
5354.4 ± 2652.7
5358.6 ± 2290.1
Subgroup analysis revealed that rotavirus was the sole pathogen in 25 children of the study group and 26 children of the control group. No significant differences in duration of diarrhoea (P = 0.5), frequency of stool (P = 0.6), stool output (P = 0.8), ORS intake (P = 0.8) and intake of other fluids (P = 0.8) were observed between these two rotavirus-infected groups of children (Table 4). The study product used as probiotic was well received and tolerated by all children. No adverse event or complication was observed during hospital stay and during follow up period of 15 days after discharge.
Table 4. Outcome variables of rotavirus associated diarrhoea in children
Study group (n = 25)
Control group (n = 26)
Results expressed in mean (±SD).
Duration of diarrhoea (h)
28.7 ± 18.8
32.5 ± 17.8
Stool output (g)
833.4 ± 558.4
785.3 ± 512.9
Frequency of stool (no)
11.7 ± 8.4
13.2 ± 8.8
ORS intake (ml)
1450 ± 633.1
1508.7 ± 693.1
Liquid + plain water (ml)
4920.9 ± 2326.8
4714.5 ± 2466.1
This double blind controlled clinical trial showed no beneficial effect of L. sporogenes (B. coagulans) as probiotic in the treatment of diarrhoea irrespective of etiological agents or rotavirus specific diarrhoea in children. We did not expect 25% reduction but expected trend of reduction of outcome variables in subgroup of children who suffered from rotavirus associated diarrhoea. We did not undertake a quantitative and qualitative study of microbial content of the L. sporogenes (B. coagulans) preparation used as probiotic. We conducted this trial to evaluate the clinical efficacy of this agent, which is one of the most commonly marketed probiotic preparations in India and is prescribed frequently by paediatricians for treatment of diarrhoea in children.
We used L. sporogenes species as probiotic preparation in this trial but we used both the terms L. sporogenes and B. coagulans in spite of knowing the fact that there is strong contradiction on nomenclature of L. sporogenes which should be referred as B. coagulans and use of this species as probiotic preparation on taxonomic basis is also debatable (Sanders et al. 2003; Vecchi & Drago 2006). Though we conducted the study during 2003–2005, the question of safe use of L. sporogenes (B. coagulans) as probiotic preparation (Sanders et al. 2003; Vecchi & Drago 2006) delayed our publication. Bacillus species, except Bacillus cereus and Bacillus anthracis, are generally regarded as non pathogenic but it was felt that the safety of L. sporogenes (B. coagulans) as probiotic preparation should be evaluated by an independent panel of experts (Vecchi & Drago 2006). However, we did not observe any adverse event or complication in the study children during their hospital stay or the follow up period of 15 days after discharge.
This probiotic preparation has been marketed in many countries, because it is cheap to produce, easy to prepare, robust to production process and has a long shelf life over wide range of temperatures; it is quite stable in formulation of powder, granules, dry syrup, tablets, capsule, resistant to high moisture and oxygen, and compatible with pharmaceutical ingredients such as vitamins, minerals, amino acids (Vecchi & Drago 2006). Despite these properties, use of this bacterium as probiotic preparation is still debated and based on only three human studies. Two studies reported the data from the same open level studies which showed the reduction of serum cholesterol levels (Mohan et al. 1990a,b). In a more recent study, fructo-oligosaccharide (FOS) in combination with L. sporogenes (B. coagulans) preparations were evaluated in a multi centre, randomised, double blind study which documented efficacy of these products in combination for prevention of antibiotic associated diarrhoea (La Rosa et al. 2003).
Numerous RCTs documented the beneficial effect of probiotic strains to treat diarrhoea in children in developed countries. The most commonly used strains belong to genera Lactobacillus, Bifidobacterium, Streptococcus, Escherichia coli strain Nissle 1917 and the yeast S. boulardii (Cornelius et al. 2002; Fox 2004; Zuccotti et al. 2008; Szajewska et al. 2007a,b). ‘Probiotics’ has become the common term to paediatricians and the general public in developed countries. By contrast, a PubMed search on use of probiotics in RCT for the treatment of diarrhoea in Indian children showed a very small number of RCTs, and that very few strains of Lactobacillus, Bifidobacteria and Streptococcus were evaluated as probiotic preparations. Dubey et al. (2008) use strains of L. acidophilus, L. casei, L. bulgaricus, L. plantarum, S. thermophilus in combination for the treatment of rotavirus-associated diarrhoea in children, which showed favourable impact. Another RCT conducted by Narayanappa et al. (2008) showed that Bifilac (Combination of probiotics) was safe and effective in patients with acute viral diarrhoea. Two studies were conducted by the same group of investigators to evaluate the efficacy of L. rhamnosus GG strain in acute watery diarrhoea in children; this showed inconsistent effect (Basu et al. 2007, 2009). No beneficial effect of tyndalised Lactobacillus acidophilus was observed in children suffering from acute diarrhoea (Khanna 2005). Inconsistent results on efficacy of probiotics for the treatment of diarrhoea in these children generated lot of controversy by the Indian experts (Bhatnagar et al. 2006). The probable explanations are (i) probiotic preparations and doses are not standardised in the Indian context; (ii) data generated in Western countries cannot be extrapolated to Indian setting as breast feeding is very common among Indian children, which may influence probiotic activities due to the presence of significant level of Bifidobacteria and Lactobacillus as intestinal microflora in breast fed children; (iii) the poor nutritional status of Indian children may have impaired immunity, poor resistance to infection, atrophy of mucosal epithelium which may alter the effects of probiotics; (iv) Indian children have different food habits, which may influence the effects of probiotics; (v) the presence of a wide variety of both helpful and harmful intestinal micro flora may modify the effects of probiotics; (vi) the heat in India may reduce the shelf life of some probiotics; (vii) the 15–20% detection rate of rotavirus as sole etiological agent of diarrhoea in Indian children is lower than in developed countries. Presently Indian experts feel that although probiotics appear promising in developed countries, there are insufficient data in Indian settings to recommend them for routine therapeutic use for the treatment of diarrhoea (Bhatnagar 2006). Our study confirms the insignificant result of L. sporogenes (B. coagulans) as probiotic preparation in the treatment of diarrhoea in Indian children.
Before generalizing the results, we must acknowledge the limitations of our study. First, we used L. sporogenes (B. coagulans) in this trial knowing that this preparation is commonly prescribed and used in developing countries though the evidences supporting probiotic activity is very sparse. Second, we feel that the sample size in the subgroup analysis of rotavirus infected children was too small. Third, this intra-mural study was not registered in the clinical trial registry because at the time registration was not mandatory. Fourth, zinc was not supplemented to the study population, as it was not common practice for the treatment of diarrhoea in children at the time of initiation of the study though it was recommended by WHO and UNICEF. However, we felt that failure of supplementation of zinc to the study population did not compromise the study result.
Diarrhoea (except cholera and shigellosis) in most of the developing countries including India is usually self-limiting and does not require active treatment except replacement of fluids and electrolytes for prevention or correction of dehydration (Bhatnagar et al. 2006; WHO 2006). However, many probiotic preparations are prescribed by physicians and available over the counter. Some probiotic preparations have proven efficacy in children in developing countries but not all. Ineffectiveness of the probiotic used in our study might be due to differences in strains used or because probiotic microorganisms already in the digestive tract of the study population might have inhibited the probiotic effect of the study drug. Probiotic preparations should be selected on the basis of convincing, locally generated efficacy data.
We acknowledge ESKAG Pharma Private Ltd, Kolkata, India for preparing the tablets of L. sporogenes and placebo used in this trial. This work was supported by the Indian Council of Medical Research (ICMR) as intramural project of National Institute of Cholera and Enteric Diseases, Kolkata, India. The sponsor had no involvement in the study design; the collection, analysis, and interpretation of data; the writing of the report; nor the decision to submit the manuscript for publication.