{"entity":{"id":"probiotics-antibiotic-stewardship-io","kind":"technology","name":"Probiotics, antibiotics and stewardship around immunotherapy","aka":[],"tldr":"Antibiotics in the weeks before immunotherapy are linked with worse outcomes, and shop-bought probiotics may not help and might hurt. Avoiding both where possible is a low-cost precaution.","summary":"Meta-analyses of more than 10,000 patients find that antibiotic exposure within about 30-60 days before starting checkpoint inhibitors is associated with roughly halved overall survival (pooled HR near 1.9), consistent across lung, kidney and melanoma cohorts, though confounding by indication (sicker patients get antibiotics) is unresolvable in observational data. Over-the-counter probiotics were associated with lower microbiome diversity and worse response in the Spencer melanoma cohort; by contrast, the specific strain Clostridium butyricum CBM588 improved PFS when added to nivolumab-ipilimumab in a small randomised trial in kidney cancer (Nature Medicine 2022, n=30). The distinction between 'probiotics' as a class and specific evidence-based strains matters. Practical stewardship: avoid prophylactic or empirical antibiotics around IO initiation where safe, narrow spectrum and shorten courses, and counsel against unselected probiotic supplements.","status":"emerging","asOf":"2026-09-08","wikipedia":"https://en.wikipedia.org/wiki/Probiotic","links":[{"label":"CBM588 + nivolumab/ipilimumab RCT (Nat Med 2022)","url":"https://doi.org/10.1038/s41591-022-01694-6"}],"tags":[],"related":["idea-bio2-antibiotic-stewardship-io"],"cancers":["nsclc","rcc","melanoma","urothelial"],"sections":["nutrition-lifestyle","immunotherapy","supportive-care"],"technologies":["checkpoint-inhibitor","microbiome-modulation-io","dietary-fibre-microbiome-io"],"targets":[],"drugs":["nivolumab","ipilimumab","pembrolizumab"],"companies":[],"institutions":[],"pathways":["microbiome-tumour"],"terms":["gut-microbiome-diversity"],"trials":[],"people":[],"bottlenecks":["b-immunotherapy-response","b-knowledge-diffusion"],"keyPapers":["paper-dizman-nat-med"],"journals":[],"dependsOn":[],"notes":[],"principle":"Broad-spectrum antibiotics deplete the commensal taxa and metabolites that support anti-tumour immunity; generic probiotics can reduce diversity by dominating the niche, whereas specific strains may restore favourable metabolite production.","strengths":["Large, consistent observational signal for antibiotics","Stewardship is cheap and aligns with antimicrobial resistance goals","Randomised signal for one defined strain"],"limitations":["Confounding by indication in antibiotic data","Probiotic products are unregulated and heterogeneous","No randomised stewardship trial"]},"route":"/technologies/probiotics-antibiotic-stewardship-io/","neighbours":{"idea":[{"id":"idea-nl-diet-covariates-io-trials","kind":"idea","name":"Capture diet, fibre and antibiotic exposure in every immunotherapy pivotal trial","route":"/ideas/idea-nl-diet-covariates-io-trials/"},{"id":"idea-bio2-antibiotic-stewardship-io","kind":"idea","name":"Protect the gut flora of patients about to start immunotherapy","route":"/ideas/idea-bio2-antibiotic-stewardship-io/"}],"cancer":[{"id":"urothelial","kind":"cancer","name":"Bladder & urothelial cancer","route":"/cancers/urothelial/"},{"id":"melanoma","kind":"cancer","name":"Melanoma","route":"/cancers/melanoma/"},{"id":"nsclc","kind":"cancer","name":"Non-small-cell lung cancer","route":"/cancers/nsclc/"},{"id":"rcc","kind":"cancer","name":"Renal cell carcinoma","route":"/cancers/rcc/"}],"section":[{"id":"nutrition-lifestyle","kind":"section","name":"Diet, Exercise & Lifestyle","route":"/fronts/nutrition-lifestyle/"},{"id":"immunotherapy","kind":"section","name":"Immunotherapy","route":"/fronts/immunotherapy/"},{"id":"supportive-care","kind":"section","name":"Supportive Care & Survivorship","route":"/fronts/supportive-care/"}],"technology":[{"id":"dietary-fibre-microbiome-io","kind":"technology","name":"Dietary fibre and the gut microbiome for immunotherapy response","route":"/technologies/dietary-fibre-microbiome-io/"},{"id":"checkpoint-inhibitor","kind":"technology","name":"Immune checkpoint inhibitors","route":"/technologies/checkpoint-inhibitor/"},{"id":"microbiome-modulation-io","kind":"technology","name":"Microbiome modulation to unlock immunotherapy","route":"/technologies/microbiome-modulation-io/"},{"id":"probiotics-treatment-diarrhoea","kind":"technology","name":"Probiotics for chemotherapy and radiotherapy diarrhoea","route":"/technologies/probiotics-treatment-diarrhoea/"}],"drug":[{"id":"ipilimumab","kind":"drug","name":"Ipilimumab","route":"/drugs/ipilimumab/"},{"id":"nivolumab","kind":"drug","name":"Nivolumab","route":"/drugs/nivolumab/"},{"id":"pembrolizumab","kind":"drug","name":"Pembrolizumab","route":"/drugs/pembrolizumab/"}],"pathway":[{"id":"microbiome-tumour","kind":"pathway","name":"Microbiome-tumour interactions","route":"/pathways/microbiome-tumour/"}],"term":[{"id":"gut-microbiome-diversity","kind":"term","name":"Gut microbiome diversity and composition","route":"/terms/gut-microbiome-diversity/"}],"bottleneck":[{"id":"b-knowledge-diffusion","kind":"bottleneck","name":"Knowledge reaches practice too slowly","route":"/bottlenecks/b-knowledge-diffusion/"},{"id":"b-immunotherapy-response","kind":"bottleneck","name":"No one can predict who responds to immunotherapy","route":"/bottlenecks/b-immunotherapy-response/"}],"paper":[{"id":"paper-dizman-nat-med","kind":"paper","name":"Nivolumab plus ipilimumab with or without live bacterial supplementation in metastatic renal cell carcinoma: a randomized phase 1 trial","route":"/key-papers/paper-dizman-nat-med/"}],"roadmap":[{"id":"nutrition-lifestyle-roadmap","kind":"roadmap","name":"Diet, exercise and lifestyle roadmap: causes established → interventions that disappointed → exercise proven as treatment","route":"/roadmaps/nutrition-lifestyle-roadmap/"}]}}