Iraqi J Pharm Sci, Vol.28(2) 2019 Lactobacillus against antibiotics associated diarrhea 179-https://doi.org/10.31351/vol28iss2pp174 DOI: 174 The Protective Effect of Lactobacillus against Ciprofloxacin and Levofloxacin Associated Diarrhea in Sample of Iraqi Patients Suha N. Muhsin*,1 and Ali F. Hassan** *Departments of Pharmacognosy, College of Pharmacy, University of Thiqar, Thiqar, Iraq. * Departments of Pharmacology and Toxicology, College of Pharmacy, University of Baghdad, Baghdad, Iraq. Abstract Fluoroquinolones drugs are important classes of wide spectrum antibacterial agents that are active against a wide range of Gram-negative and Gram-positive pathogens; they are divided into four generations. Specific types of antibiotics have been associated with side effect like diarrhea, this called (collateral damage), which may occur due to drug-resistant organisms and the unwanted development of colonization or infection with multidrug- resistant organisms. This damage is mostly related to levofloxacin and Ciprofloxacin. The aim of the current study was to compare the incidence of collateral damage between two quinolone antibiotic derivatives (ciprofloxacin and levofloxacin) and to evaluate the activity of lactobacillus to reduce the collateral damage. This study was carried out on 100 patients. Administration of ciprofloxacin, levofloxacin each alone or in combination with lactobacillus; the character of diarrhea and the grade of diarrhea was studied before and after 10 days of administration each dosing protocol. The results for this study, there are a significant increase in the incidence of diarrhea for all groups when comparison between before and after treatment diarrhea was made; a number of patients with diarrhea in group 1 after finish the treatment was not significantly higher when compared with group 2 (P>0.05); meanwhile, number of patients with diarrhea in group 4 after finish the treatment was significantly lower when compared with group 3 (P<0.05). it can concluded that , The use of ciprofloxacin and levofloxacin associated with incidence of collateral damage represented as diarrhea and levofloxacin is the least risk of this damage, and using of lactobacillus with levofloxacin was better results than the other three groups. Key words: Collateral damage, Ciprofloxacin, Levofloxacin, Lactobacillus. السبروفلوكساسين و االسهال المصاحب الستعمال تقييم التاثير الوقائي للالكتوباسيالس ضد المرضى العراقيين عينة من الليفوفلوكساسين في **و علي فارس حسن 1*،محسنناظم ا هس *فرع العقاقير ، كلية الصيدلة ، جامعة ذي قار ، ذي قار ، العراق . .العراق ،بغداد،جامعة بغداد،كلية الصيدلة، فرع االدوية** الخالصة البكتريا ة الغرام والموجب البكترياة ضد يفعال طيف والتي تمتلك من مضادات البكتيريا الواسعة ال من األنواع المهمةأدوية الفلوروكوينولون تعد أرتبطت بتأثير جانبي مثل االسهال, هذا مايعرف بالضرر الجانبي الذيمن المضادات الحيوية أنواع محددةتقسم الى اربعة أجيال. و السالبة الغرام مقاومه لعدة أدوية. هذا الضرر هو معظمه يتعلق عضياتء وتطور غير مرغوب به لالستيطان أوعدوى مع مقاومة للدوا نتيجة لعضياتحصل ي بالسبروفلوكساسين والليفوفلوكساسين. ين سين مشتقين من مجموعة الكوينولون )سبروفلوكسايلمقارنة امكانية ظهوراالضرار الجانبية بين مضادين حيو من الدراسة الحالية هوالهدف ان أدوية اعطاءم . تهذه الدراسة تم تنفيذها على مائة مريض. و ليفوفلوكساسين( وتقييم فعالية الالكتوباسلس في تقليل ظهوراالضرار الجانبية يام من أ, تم دراسة حالة االسهال وتدرجات األسهال درست قبل وبعد عشرة الالكتوباسلسمع وبشكل مفرد أو الليفوفلوكساسين االسبروفلوكساسين هناك زيادة معنوية في حدوث األسهال لكل المجاميع عند المقارنة فيما بين قبل وبعد معالجة األسهال, اظهرت النتائج ان أعطاء الجرعة المتفق عليها. وان ,(P<0.05)وعة الثانية ان عدد المرضى الذين يعانون من األسهال في المجموعة األولى بعد نهاية المعالجة هو أعلى معنويا بالمقارنة مع المجم استخدام ان. (P<0.05)عدد المرضى الذين يعانون من االسهال في المجموعة الرابعة هو أقل معنويا عند المقارنة بالمجموعة الثالثة ن ن حيث الضرر, واطرا محدوث االضرار الجانبية المتمثلة باالسهال و الليفوفلوكساسين هو االقل خب ارتبطالسبروفلوكساسين والليفوفلوكساسين المجاميع الثالث االخرى. بخالفافضل النتائج أعطىستخدام الالكتوباسلس مع الليفوفلوكساسين أ : االضرار الجانبية, سبروفلوكساسين, ليفوفلوكساسين, الكتوباسلس.ةالكلمات المفتاحي Introduction Fluoroquinolones are synthetic drugs having broad spectrum of antibacterial activity and they are broadly used to treat or prevent infectious diseases (1). They are greatly active against both Gram- positive and Gram – negative microorganisms and have metabolic properties that are promising for treating extensive types of infections; they are active against Streptococcus pneumonia, Mycoplasma pneumoniae, Chlamydophila pneumonia and Pseudomonas aeruginosa (2). ali_1371982@yahoo.commail:-or ECorresponding auth1 Received: 3/7 /2019 Accepted: 6/9 / 2019 Iraqi Journal of Pharmaceutical Sciences https://doi.org/10.31351/vol28iss2pp174-179 Iraqi J Pharm Sci, Vol.28(2) 2019 Lactobacillus against antibiotics associated diarrhea 175 Furthermore, fluoroquinolones inhibited either - DNA gyrase, which is an adenosine triphosphate- hydrolyzing topoisomerase II enzyme to keep safe the state of supercoiling in replicating and non- replicating chromosomes of bacteria or -action of topoisomerase IV (3). Moreover, fluoroquinolones indicated for the treatment of different types of infections like urinary tract infections, chronic bacterial prostatitis, acute uncomplicated cystitis in females (4), skin and skin- structure infections, bone and joint infections (5) and -gastrointestinal infections (6). Ciprofloxacin is a second-generation fluoroquinolone, is carboxylic acid derivatives of fluoroquinolones, and the most beneficial and it is widely used among fluoroquinolone drugs (7). Levofloxacin is a third generation fluoroquinolone which is the optical S-(-) isomer of ofloxacin. Levofloxacin have an extended antibacterial range and new different uses when compared with older generations of fluoroquinolone (8, 9). Antibiotic associated diarrhea is a most important type of collateral damage that associated with the uses of specific type of antibiotics. The major causes of this adverse effect are the presence of drug-resistant organisms and the inadequate development of colonization or occurrence of multidrug-resistant pathogens (10, 11). Lactobacilli are live bacterial agents without any adverse effects (12). Lactobacillus considered a probiotics which use as a dietary supplements. Lactobacillus containing different types of bacteria including (Lactobacillus species, Bifidobacterium species, and others). The clinical use of lactobacillus was supports health by improving the normal flora of the gastrointestinal tract (GIT) (13). Moreover, Lactobacillus can also compete with microorganisms for food and adhesion places on the gastrointestinal mucosa (14). Besides probiotics can regulate local and systemic immune responses by enhancing the secretion of immunoglobulin IgA (15). The aim of the current study was to compare the incidence of diarrhea associated with the use of two quinolone antibiotic derivatives (ciprofloxacin and levofloxacin) and evaluate the protective activity of lactobacillus against diarrhea associated with these two antibiotics. Patients and Methods Patients The current prospective study was carried out on 100 patients who diagnosed by gynecologist or urologist or internist having one type of infections which is either typhoid fever , urinary tract infections or gynecological diseases during August 2018 to March 2019. The age of patients range from (18-60) years. Study design A prospective study of cohort of 100 patients, divided as: * Group 1- include 25 patients, taking ciprofloxacin (ciprodar) (R) 500mg tablet twice daily for 10 day (16). * Group 2- includes 25 patients, taking ciprofloxacin (ciprodar) (R) 500 mg tablet twice daily (16) plus lactobacillus (Vitalactic B) (R) 50 mg capsule twice a day for 10 days (17). * Group 3- include 25 patients, taking levofloxacin (Tavanic) (R) 250 mg tablet twice daily for 10 days (16). * Group 4- include 25 patients, taking levofloxacin (Tavanic) (R) at dose 250 mg tablet twice daily (16) plus lactobacillus (Vitalactic B) (R) 50 mg capsule twice a day for 10 days (17) Inclusion Criteria The Inclusion criteria for this study were: 1- Patients did not use antibiotic for last three months 2- Patients did not have diarrhea 3- Patients in both sexes at age range from (18-65) years Exclusion Criteria The exclusion criteria for this study were: 1- Patients with bowel diseases like (irritable bowel syndrome). 2- Patients in at age less than 18. 3- Patient with allergic reaction against fluoroquinolone. Diarrhea grade Diarrhea grade was divided as follow (grade 1 less than 4 times /day over baseline, grade 2 between 4-6 times /day over baseline, grade 3 more than 7 times /day over baseline, grade 4 life- threatening diarrhea (18). Statistical analysis All results were expressed as frequencies for each category with calculation of percent for each frequency. Data were analyzed by utilizing computerized statistical package for the social sciences (SPSS) program version 24. Chi square test was performed for test groups to evaluate dependency, if P values < 0.05 were considered to be significantly dependent. Ethical consideration All patients included in this study were informed about the aim of the study and they agree to participate in this study and their consent was obtained. Results Characteristics of diarrhea Table 1 and figure 1 showed that, in group 1 there are a significant differences in the presence of diarrhea when comparison was made between patients before starting treatment protocols (4%) and after finishing the treatment protocol (68%) (P<0.05). Iraqi J Pharm Sci, Vol.28(2) 2019 Lactobacillus against antibiotics associated diarrhea 176 Moreover, in group 2, there are significant differences in the presence of diarrhea when comparison was made between patients before stating treatment protocols (4%) and after finishing the treatment protocol (44%) (P<0.05).Table 1 and figure 1. Furthermore, table 1 and figure 1 showed that in group 3, there are significant differences (P<0.05) in the presence of diarrhea when comparison was made between patients before stating treatment protocols (0%) and after finishing the treatment protocol (44%). Moreover, in group 4, there are significant differences in the presence of diarrhea when comparison was made between patients before stating treatment protocols (4%) and after finishing the treatment protocol (24%) (P<0.05). Table 1. The presence of diarrhea in patients before and after a specific medication protocol. Patients with diarrhea Patients without diarrhea P- Value Group 1 Before 1(4%) 24(96%) 5.31E- 05 After 17(68%) 8(32%) Group 2 Before 1(4%) 24(96%) 0.0132 After 11(44%) 14(56%) Group 3 Before 0(0%) 25(100%) 0.0117 After 11(44%) 14(56%) Group 4 Before 1(4%) 24(96%) 0.0415 After 6(24%) 19(76%) - Number of patients for each group =25, chi square test use to evaluate the dependency in the presence of diarrhea before treatments and after the treatment in the study groups * Group 1 taking ciprofloxacin 500mg tablet twice daily for 10 day. * Group 2 taking ciprofloxacin 500 mg tablet twice daily plus lactobacillus 50 mg capsule twice a day for 10 days * Group 3 taking levofloxacin 250 mg tablet twice daily for 10 days * Group 4 taking levofloxacin at dose 250 mg tablet twice daily plus lactobacillus 50 mg capsule twice a day for 10 days - The value between two brackets represents a percent of patients with or without diarrhea. Figure 1. Incidence of diarrhea before and after a specific medication protocol . Group 1 patients taking ciprofloxacin 500mg tablet twice daily for 10 day. Group 2 patients taking ciprofloxacin 500 mg tablet twice daily plus lactobacillus 50 mg capsule twice a day for 10 days Group 3 patients taking levofloxacin 250 mg tablet twice daily for 10 days Group 4 patients taking levofloxacin at dose 250 mg tablet twice daily plus lactobacillus 50 mg capsule twice a day for 10 days. Table 2 showed that in group 1, the number of patients having diarrhea after the end of treatment was (17 patients) which is higher when compared to group 2 patients (11patients). Furthermore, there are a significant differences in the presence and absence of diarrhea in group 1 as compare to patients in group 2 (P<0.05). Moreover, in group 3, a number of patients having diarrhea was (11 patients) after the end of treatment which is higher when compared with group 4 in which the number of patient having diarrhea was (6 patients). Additionally, there are significant differences (P<0.05) in the presence and absence of diarrhea in group 3 as compare to patients in group 4. Iraqi J Pharm Sci, Vol.28(2) 2019 Lactobacillus against antibiotics associated diarrhea 177 Table 2. Comparison in the incidence of diarrhea for patients after taking either ciprofloxacin or levofloxacin with patients taking ciprofloxacin and lactobacillus or levofloxacin and lactobacillus. Patients with diarrhea Patients without diarrhea p-value Group 1 17 8 0.0873752 Group 2 11 14 Group 3 11 14 0.0005764 Group 4 6 19 -Data express as total number of patients, N=25, chi square was use to evaluate the dependent between two study group in which (p<0.05) considered as significant dependence * Group 1 taking ciprofloxacin 500mg tablet twice daily for 10 day. * Group 2 taking ciprofloxacin 500 mg tablet twice daily plus lactobacillus 50 mg capsule twice a day for 10 days. * Group 3 taking levofloxacin 250 mg tablet twice daily for 10 days * Group 4 taking levofloxacin at dose 250 mg tablet twice daily plus lactobacillus 50 mg capsule twice a day for 10 days - The value between two brackets represents a percent of patients with or without diarrhea. Table 3showed that in group 1, a number of patients having diarrhea was (17) after the end of treatment; meanwhile, in group 3 (11 patients) having diarrhea; and, there are no significant differences (P>0.05) in the presence and absence of diarrhea in group 1 as compared to that in group 3 patients. Additionally, table 3 showed that, in group 2, number of patients having diarrhea was (11) after the end of treatment; meanwhile, in group 4 (6 patients) having diarrhea; and, there are no significant differences in the presence and absence of diarrhea in group 2 as compared to that in group 4 patients (P>0.05). Table 3. Comparison in the incidence of diarrhea for patients after taking ciprofloxacin with levofloxacin and patients taking ciprofloxacin plus lactobacillus with patient taking levofloxacin plus lactobacillus. Patients with diarrhea Patients without diarrhea p-value Group 1 17 8 0.087375 Group 3 11 14 Group 2 11 14 0.135515 Group 4 6 19 -Data express as total number of patients, N=25, chi square was use to evaluate the dependent between two study group in which (p<0.05) considered as significant dependence * Group 1 taking ciprofloxacin 500mg tablet twice daily for 10 day. * Group 2 taking ciprofloxacin 500 mg tablet twice daily plus lactobacillus 50 mg capsule twice a day for 10 days. * Group 3 taking levofloxacin 250 mg tablet twice daily for 10 days * Group 4 taking levofloxacin at dose 250 mg tablet twice daily plus lactobacillus 50 mg capsule twice a day for 10 days - The value between two brackets represents a percent of patients with or without diarrhea. Discussion The fluoroquinolone class of antimicrobial agents which is active against an extensive range of multi-resistant microorganisms due to its mode of action against different molecular targets than other antibacterial classes (19). Antibiotic associated diarrhea or collateral damage considered a serious adverse effect associated with the use of fluoroquinolones antibiotic therapy; such type of adverse effect had especial concern when initiating empirical antibiotic therapy, especially in patients who are seriously immune-compromised or ill (20). In tables 1, 2, and 3, all the groups of patients have a diarrhea after finishing the treatments protocol and this induction was significant differences when compare with same group before the treatment protocol started, besides the addition of lactobacillus to the ciprofloxacin show a not- significant improvement in the diarrhea but the addition of lactobacillus to the levofloxacin show a significant improvement in the induction of diarrhea when compared to levofloxacin alone. At the same time in (Table 4), there are significant differences in the grade of diarrhea in groups1, 2, 3 and 4 when Iraqi J Pharm Sci, Vol.28(2) 2019 Lactobacillus against antibiotics associated diarrhea 178 compare between before start treatment and after finish the treatment protocol. Margaret EM, et al at 2003 showed that drugs belong to fluoroquinolone group may have the ability to prompt diarrhea (21). Probiotics (live microorganisms) can give a health advantages on the host when taken in a sufficient amounts (22). Authors mentioned that the purpose behind taking probiotics in gastrointestinal disorders is based on the theory that probiotics may help in normalization of an unbalanced flora in GIT. Moreover, probiotics may promote intestinal health by the induction of immunity, competition for nutritional components of foods, or the inhibition of epithelial invasion (23). The clinical study for Lactobacillus showed that it had the ability to prevent many clinical conditions, such as the treatment of lactose intolerance and the prevention and treatment of nosocomial diarrhea (24). Guandalini S, et al (2000) reported that when lactobacillus has been used in adults and children having an acute diarrhea and treated with lactobacillus, the recurrence of diarrheal symptoms were reduced (25). Results of the current study are matched with those of previous one; where, the use of ciprofloxacin and levofloxacin alone associated with increasing the incidence of diarrhea and at the same time, ciprofloxacin has the ability to induce diarrhea higher than that produced by levofloxacin as seen in table 2; furthermore, the addition of lactobacillus to the treatment protocol caused reduction in the incidence of diarrhea in each treatment (groups 2 and 4), and the reduction in the incidence was significantly higher in group 4 when compared to the incidence of diarrhea in group 2. The same findings have been seen concerning the grade of diarrhea. Conclusions The use of ciprofloxacin and levofloxacin associated with increasing the incidence of collateral damage represented as diarrhea; and levofloxacin produced the least risk of this damage; and the use of lactobacillus with levofloxacin produced better results. References 1. Robicsek A, Strahilevitz J, Jacoby G A, et al. 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