Analyzing Proton Pump Inhibitor (PPI) induced dysbiosis and growing role of probiotics: Review

Dr. Mitul Prakashbhai,

Comprising a diverse plethora of bacterial species, the human intestinal microecology is considered a complex community. Among the many underlying etiologies that can lead to Small interstitial bacterial overgrowth (SIBO), Proton pump inhibitors (PPI) have come under the scanner owing to recent study results showing that PPIs provoke dysbiosis of the small intestinal bacterial flora, exacerbating NSAID-induced small intestinal injury [1].

Both clinicians and patients should be judicious in the use of PPI and consider dose-tapering whenever possible. Owing to the multiple adverse effects linked to chronic use of antibiotics in managing SIBO, research has shifted focus to more therapeutic alternative probiotics. Probiotic therapy is an effective option for SIBO decontamination, reduction in H2 concentration, and abdominal pain relief.

Taking into account the potential adverse effects associated with chronic antibiotic therapies in managing PPI-induced SIBO, the addition of probiotics is regarded to be a new leap forward. Opening up new horizons in the treatment of SIBO, growing evidence now highlights the potency of probiotics in the prevention as well as eradication of SIBO.

Comments of D. Suryaprabha

In an era in which gut microbiota science enjoys much attention [2,3], it seems crucial to define which types of drugs have an impact on gut microbiota composition. Side effects of proton pump inhibitors (PPI) can be linked to the changes in the intestinal microbiome that occur during therapy, especially in long-term users. The evidence indicates that PPIs which are widely used in gastroenterology clinical practice likely through their acid-antisecretory effects, are able to modify the host microbiota in each segment of the GI tract and can contribute to dysbiosis development; this dysbiosis can, in turn, facilitate the onset of certain GI disorders. Moreover, the gastric hypochlorhydria caused by PPIs favours the survival and migration of oral bacteria in lower areas of the GI tract, with a possible establishment of a pro-inflammatory microenvironment. Further prospective studies are necessary to define how the microbial changes due to PPIs impact human health. Moreover, therapeutic strategies, such as probiotic supplementation, could be a useful approach to prevent dysbiosis during PPI treatment; however, the validity of this observation remains to be seen. Currently, the use of PPIs is recommended only when strictly necessary due to their possible ability to induce dysbiosis.


  1. Bruno G. Proton pump inhibitors and dysbiosis: Current knowledge and aspects to be clarified. World J Gastroenterol. 2019;25(22):2706-19.
  2. Guarner F. Decade in review-gut microbiota: The gut microbiota era marches on. Nat Rev Gastroenterol Hepatol. 2014;11:647-9.
  3. O’Grady J, O’Connor EM, Shanahan F. Review article: Dietary fibre in the era of microbiome science. Aliment Pharmacol Ther. 2019;49:506-15.

D. Suryaprabha

Senior Executive-Clinical Research