Localized Impact of Zinc and Probiotics on Antibiotic-Associated Diarrhea in Children: A Perspective from Southern Iran

Localized Impact of Zinc and Probiotics on Antibiotic-Associated Diarrhea in Children: A Perspective from Southern Iran | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Localized Impact of Zinc and Probiotics on Antibiotic-Associated Diarrhea in Children: A Perspective from Southern Iran Mohammad Bagher Rahmati, Razieh khodadadzade, Mehran Ahmadi, Saeed Hoseini teshnizi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6295667/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background: Antibiotic-associated diarrhea (AAD) is a frequently encountered complication that arises from the administration of antimicrobial agents. Objective: The aim of this study was to evaluate the efficacy of zinc and probiotics in reducing antibiotic-associated diarrhea (AAD) incidence, hospitalization, and treatment duration.. Patients and methods: This is a randomized clinical trial involving 165 children referred to Bandar Abbas Children's Hospital, which necessitated antibiotics for any given reason. They were randomly assigned to three groups of equal size, exclusively receiving the standard antibiotic regimen or the zinc and probiotics groups. Age, sex, length of hospital stay, treatment duration, type of antibiotic, and incidence AADwere documented for all patients. Results: Among the 165 children who participated in the survey, AAD occurred in 12.7% of the zinc group, 9.1% of the probiotics group, and 10.9% of the control group; however, the difference among the groups was not statistically significant (P=0.829). There was no significant association between AAD and age, sex, hospital length of stay, type of antibiotic, or patient grouping. Conclusions: Despite the lower incidence of AAD, duration of hospital stay and duration of treatment in children in the probiotic group, these findings were not statistically significant. antibiotic-associated diarrhea children zinc probiotics 1. Introduction Over the past two decades, numerous studies have elucidated the clinical benefits and safety profiles of a diverse array of probiotics in the prevention and management of gastrointestinal diseases (1,2,3). The use of probiotics as preventive interventions against antibiotic-associated diarrhea (AAD) in pediatric populations has gained considerable traction. AAD is a prevalent adverse effect associated with antibiotic therapy, leading to significant discomfort and complications (4). Specifically, two probiotic strains, Lactobacillus rhamnosus GG and Saccharomyces boulardii, are recommended for the prevention of AAD in children (5). Lactobacillus rhamnosus GG has demonstrated efficacy in reducing both the incidence and duration of AAD among pediatric patients. A previous study indicated that children administered Lactobacillus rhamnosus GG exhibited a significantly lower risk of developing AAD compared to those receiving a placebo (6). Similarly, Saccharomyces boulardii has been identified as another effective probiotic strain for preventing AAD in children (6,8). Regarding dosage, clinical trials have reported that a higher dose range of 5–40 billion colony-forming units per day is associated with optimal efficacy (6). While probiotics are typically regarded as safe for healthy children, it is important to note that rare but serious adverse events have been documented in severely debilitated or immunocompromised pediatric populations (7). In conclusion, probiotics—specifically Lactobacillus rhamnosus GG and Saccharomyces boulardii—have shown effectiveness in preventing antibiotic-associated diarrhea among children (5). Zinc supplementation has demonstrated promising outcomes in the prevention and treatment of antibiotic-associated diarrhea (AAD) in pediatric populations (9). AAD is a prevalent adverse effect associated with antibiotic use, and numerous studies have investigated the role of zinc in mitigating the severity and duration of diarrhea (10). Zinc is an essential micronutrient that plays critical roles in immune response, cellular proliferation, and protein synthesis. Research indicates that zinc enhances the absorption of water and electrolytes in the intestines, contributing to a reduction in both the duration and severity of diarrhea (11). Furthermore, zinc supplementation has been shown to prevent subsequent infections for 2 to 3 months post-administration. The acceptability of zinc supplementation among both children and caregivers is generally high, and its efficacy appears to be consistent regardless of the specific zinc salt used (e.g., zinc sulfate, zinc acetate, or zinc gluconate) (12). 2. Objectives The objective of this study was to evaluate and compare the effects of zinc and probiotics on children aged 3 months to 12 years diagnosed with antibiotic-associated diarrhea (AAD) in southern Iran. While zinc supplementation and probiotics have shown promising outcomes in managing diarrhea, further research is necessary to determine their efficacy, particularly in the prevention and treatment of AAD in pediatric populations. 3. Materials and methods 3,1. Study Design The study included a zinc group, a probiotics group, and a control group. The zinc group received oral zinc supplementation, specifically 2.5 ml every 12 hours for children under 1 year of age and 5 ml every 12 hours for older children. The probiotics group received one sachet of KidiLact daily, which contained Lactobacillus rhamnosus, Lactobacillus reuteri, Bifidobacterium infantis, and other strains, totaling 5 billion CFU. The control group received the standard antibiotic regimen without any additional supplementation. Interventions commenced within 24 hours of antibiotic initiation and continued for seven days. Antibiotic-associated diarrhea (AAD) was defined as the occurrence of three or more loose stools per day for two consecutive days during or within two weeks of antibiotic use. The Bristol stool scale was employed to classify stool consistency. The incidence of AAD was assessed and compared among the three groups, along with the evaluation of other parameters such as hospitalization and treatment < 1 year and 5 ml every 12 hours for older children; the probiotics group received 1 sachet of KidiLact daily (containing Lactobacillus rhamnosus, Lactobacillus reuteri, Bifidobacterium infantis, and other strains, CFU: 5 billion).; and the control group received Standard antibiotic regimen without additional supplementation. Interventions started within 24 hours of antibiotic initiation and continued for seven days. AAD was defined as three or more loose stools per day for two consecutive days during or within two weeks of antibiotic use. The Bristol stool scale was used to classify stool consistency( 13 ). The incidence of AAD was assessed and compared among the three groups. 3,2. Data collection and statistical analysis After the desired information was collected, it was entered into SPSS software version 26 and subsequently analyzed using descriptive statistics. Chi-square tests and Fisher's exact tests were employed to compare qualitative variables between the study groups. Due to the non-normality of the distribution of quantitative variables, as indicated by the Kolmogorov‒Smirnov test, the Kruskal‒Wallis and Mann‒Whitney tests were utilized to compare quantitative variables across groups. Additionally, logistic regression was applied to identify the factors influencing the incidence of AAD. 3,3. Ethical considerations This study was conducted in accordance with the tenets of the Declaration of Helsinki and was ethically approved by the Ethics Committee of Hormozgan University of Medical Sciences (Approval ID: IR.HUMS.REC.1399.579). Informed consent was obtained from the children and their parents. Clinical trial number is not applicable. 4. Results In this study, a total of 165 children aged between 3 months and 12 years were investigated. The participants had an average age of 45.65 ± 41.46 months(Table 1 ). Among the total sample, 84 (50.9%) were boys, and 81 (49.1%) were girls(Table 2 ). AAD incidence was 12.7% in the zinc group, 9.1% in the probiotic group, and 10.9% in the control group (P = 0.829). Hospitalization and treatment durations were significantly shorter in the probiotic group than in the zinc group (P < 0.001) (Table 3 , 4 ). Ampicillin consumption was observed in 16.4% of the probiotics group, 3.6% of the control group, and 1.8% of the zinc group (P = 0.013). Additionally, vancomycin consumption was observed in 10.9% of the control group and 7.3% of the zinc group, whereas no patients in the probiotics group received vancomycin (P = 0.037)Table 5 . No significant differences were found among the groups in terms of the consumption of ceftriaxone, meropenem, cefotaxime, or clindamycin. There was no significant association between AAD and age, sex, hospital length of stay, type of antibiotic, or patient grouping. Table 1 Comparison of age between study groups Variable Groups P-value Control(55 persons) (IQR)* Probiotic(55persons) (IQR) Zinc(55 persons) (IQR) Age (months) (96–19) 41 (42–6) 20 (80–14) 40 0.001 * IQR، interquartile range Table 2 Comparison of gender between study groups Sex Groups P-value Control(55 persons) % Probiotic(55 persons) % Zinc(55 persons) % Male 25 (5/45) 30 (5/54) 29 (7/52) 601/0 Female 30 (5/54) 25 (5/45) 26 (3/47) Table 3 Comparison of the incidence of diarrhea between study groups Diarrhea Groups P value Control(55 persons) % Probiotic(55 persons) % Zinc(55 persons) % No 49 (1/89) 50 (9/90) 48 (3/87) 829/0 Yes 6 (9/10) 5 (1/9) 7 (7/12) Table 4 Comparison of hospital stay and treatment duration between study groups P-value Groups Variables Control(55 persons) (IQR) Probiotic(55 persons) (IQR) Zinc(55 persons) (IQR) 001/0 ( 5 – 2 ) 3 ( 3 – 1 ) 2 ( 5 – 2 ) 4 Hospital stay (day) 001/0 ( 5 – 2 ) 3 ( 3 – 1 ) 2 ( 5 – 2 ) 4 Treatment Time(day) P-value Groups Antibiotic Control(55 persons) % Probiotic(55 persons) % Zinc(55 persons) % 171/0 47 (5/85) 46 (6/83) 52 (5/94) Ceftriaxon 013/0 2 (6/3) 9 (4/16) 1 (8/1) Ampicillin 037/0 6 (9/10) 0 (0) 4 (3/7) Vancomycin 128/0 4 (3/7) 0 (0) 1 (8/1) Meropenem 117/0 4 (3/7) 9 (4/16) 3 (5/5) Cefotaxim 178/0 8 (5/14) 6 (9/10) 13 (6/23) Clindamycin Table 5 Comparison of antibiotic type between study groups P-value Adjusted OR (95% CI) P-value Crude OR (95% CI) variable 466/0 (009/1–981/0) 995/0 635/0 (010/1–985/0) 997/0 Age Male Sex 313/0 (641/1–213/0) 591/0 362/0 (709/1–231/0) 628/0 Female Control Groups 916/0 (544/3–321/0) 067/1 768/0 (802/3–373/0) 191/1 Zinc 501/0 (385/2–169/0) 635/0 751/0 (852/2–234/0) 817/0 Probiotic 000/1 (؟ − 0) 158/1 382/0 (069/20–317/0) 523/2 Ceftriaxon Antibiotic 999/0 (؟ − 0) 6/189797070 767/0 (988/5–088/0) 727/0 ampicillin 675/0 (641/25–122/0) 771/1 924/0 (564/7–108/0) 902/0 Vancomycin 000/1 (0–0) 0 999/0 (0–0) 0 Meropenem 000/1 (0–0) 0 536/0 (170/4–064/0) 518/0 Cefotaxim 975/0 (194/4–250/0) 023/1 971/0 (816/3–275/0) 025/1 Clindamycin 714/0 (184/1–781/0) 962/0 881/0 (166/1–836/0) 987/0 Hospital stay 5. Discussion The present study observed that probiotic supplementation was associated with a lower incidence of AAD and reduced hospitalization and treatment durations compared to zinc; however, these differences did not reach statistical significance. These findings contrast with prior studies that reported zinc as more effective in accelerating diarrhea recovery (14, 15). This discrepancy may be attributed to contextual factors in Southern Iran, including regional dietary patterns, healthcare practices, and the specific multi-strain probiotic formulation utilized in this trial. The inclusion of diverse bacterial strains in the probiotic intervention (e.g., Lactobacillus and Bifidobacterium species) may have enhanced its efficacy, consistent with evidence suggesting that synergistic probiotic combinations yield broader therapeutic effects than single strains (16). The comparative effectiveness of zinc and probiotics remains a topic of ongoing debate. Cai J et al. (17) assessed the efficacy of zinc, probiotics, and their combination in children with AAD, concluding that the combined regimen was more effective than monotherapies—an assertion that contrasts with the findings of the current study. Similarly, Azim et al. (18) demonstrated that the combination of zinc and probiotics was more effective in reducing the severity of acute gastroenteritis compared to zinc alone. Discrepancies in study design, including variations in inclusion criteria (such as diarrhea etiology and patient demographics), differing zinc dosage forms (e.g., sulfate versus acetate), and diverse probiotic compositions likely contribute to these conflicting results. Additionally, the objectives of earlier studies—whether aimed at diarrhea prevention or treatment—may influence the observed outcomes. For example, Tai et al. (19) found that zinc supplementation shortened the duration of AAD in hospitalized children but did not affect disease severity, whereas Zarin Far et al. (20) reported that Lactobacillus probiotics did not reduce the incidence of AAD but alleviated symptoms of colitis. This heterogeneity highlights the necessity of standardizing interventions and outcomes in future research endeavors. Notably, neither zinc nor probiotics in this study significantly reduced hospitalization or treatment duration compared to the control group. This finding contrasts with the conclusions of Huang et al.’s meta-analysis (16), which indicated that probiotics effectively shortened diarrhea duration and hospitalization. The null effect observed in this study may reflect regional differences in baseline microbiota, variations in antibiotic prescribing practices, or differences in pathogen prevalence. Furthermore, the relatively small sample size and the non-uniform probiotic formulations across studies complicate direct comparisons. Emerging evidence suggests that combination therapies may offer synergistic benefits. Xiang et al. (9) reported that the administration of zinc in conjunction with probiotics was more effective than probiotics administered alone in managing pneumonia-related antibiotic-associated diarrhea (AAD). Additionally, Hassan et al. (16) and Azim et al. (18) both emphasized the superiority of dual therapy. These findings imply that zinc and probiotics may target distinct biological pathways—zinc enhances intestinal immunity while probiotics restore microbial balance—thereby justifying further exploration of their combined use. Conclusion The present study underscores the potential efficacy of multi-strain probiotics in managing AAD while emphasizing the need for larger, context-specific trials to address inconsistencies in prior research. Future investigations should include a combination therapy arm (zinc plus probiotics) alongside monotherapy and control groups. Standardizing probiotic strains, zinc formulations, and outcome measures will enhance comparability across diverse populations. Additionally, research should stratify results according to the etiology of diarrhea, as pathogen-specific responses may influence treatment efficacy. Until conclusive evidence is obtained, clinical decision-making should consider regional practices, patient demographics, and available formulations. Declarations Clinical trial number: ClinicalTrials.gov Identifier: NCT06665503, 2024-10-29. Ethics Approval and Consent to Participate: This study was conducted in accordance with ethical guidelines and received approval from the Hormozgan University Ethics Committee (Approval ID: IR.HUMS.REC.1399.579). Consent for Publication: All authors consent to the publication of this manuscript. Availability of Data and Material: The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request. Competing Interests: The authors declare no competing interests. Funding: This research received no specific grant from any funding agency. Authors' Contributions: M.B.R., S.H.T., and M.A. wrote the main manuscript text. M.B.R. and R.K. collected data. S.H.T. performed the analysis and interpretation. M.B.R. and M.A. edited the manuscript. All authors reviewed and approved the final manuscript. Acknowledgements: We thank the investigators, coordinators, and patients who participated in this study, as well as the Clinical Research Development Unit (CRDU) of Bandar Abbas Pediatric Hospital. References Hill C, Guarner F, Reid G, Gibson GR, Merenstein DJ, Pot B, Morelli L, Canani RB, Flint HJ, Salminen S, Calder PC, Sanders ME. Expert consensus document. The International Scientific Association for Probiotics and Prebiotics consensus statement on the scope and appropriate use of the term probiotic. Nat Rev Gastroenterol Hepatol. 2014 Aug;11(8):506-14. doi: 10.1038/nrgastro.2014.66. Sanklecha M, Verma L, Pai U, Mishra S, Maqsood S, Birla A. Lactobacillus rhamnosus GG Evaluation in Acute Diarrhea (LEAD): An Observational Study. Cureus. 2022 Apr 29;14(4):e24594. doi: 10.7759/cureus.24594. Szajewska H, Urbańska M, Chmielewska A, Weizman Z, Shamir R. Meta-analysis: Lactobacillus reuteri strain DSM 17938 (and the original strain ATCC 55730) for treating acute gastroenteritis in children. Benef Microbes. 2014 Sep;5(3):285-93. doi: 10.3920/BM2013.0056. Kopacz K, Phadtare S. Probiotics for the Prevention of Antibiotic-Associated Diarrhea. Healthcare (Basel). 2022 Aug 2;10(8):1450. doi: 10.3390/healthcare10081450. Goldenberg JZ, Lytvyn L, Steurich J, Parkin P, Mahant S, Johnston BC. Probiotics for the prevention of pediatric antibiotic-associated diarrhea. Cochrane Database Syst Rev. 2015 Dec 22;(12):CD004827. doi: 10.1002/14651858.CD004827.pub4. Update in: Cochrane Database Syst Rev. 2019 Apr 30;4:CD004827. doi: 10.1002/14651858.CD004827. Hempel S, Newberry SJ, Maher AR, Wang Z, Miles JN, Shanman R, Johnsen B, Shekelle PG. Probiotics for the prevention and treatment of antibiotic-associated diarrhea: a systematic review and meta-analysis. JAMA. 2012 May 9;307(18):1959-69. doi: 10.1001/jama.2012.3507. Szajewska H, Kotowska M, Mrukowicz JZ, Armańska M, Mikołajczyk W. Efficacy of Lactobacillus GG in prevention of nosocomial diarrhea in infants. J Pediatr. 2001 Mar;138(3):361-5. doi: 10.1067/mpd.2001.111321. Wan CM, Yu H, Liu G, Xu HM, Mao ZQ, Xu Y, Jin Y, Luo RP, Wang WJ, Fang F. [A multicenter randomized controlled study of Saccharomyces boulardii in the prevention of antibiotic-associated diarrhea in infants and young children]. Zhonghua Er Ke Za Zhi. 2017 May 4;55(5):349-354. Chinese. doi: 10.3760/cma.j.issn.0578-1310.2017.05.008. Xiang R, Tang Q, Chen XQ, Li MY, Yang MX, Yun X, Huang L, Shan QW. Effects of Zinc Combined with Probiotics on Antibiotic-associated Diarrhea Secondary to Childhood Pneumonia. J Trop Pediatr. 2019 Oct 1;65(5):421-426. doi: 10.1093/tropej/fmy069. Selma C. Liberato, Gurmeet Singh, Kim Mulholland. Inc. supplementation in young children: A review of the literature focusing on diarrhea prevention and treatment. Volume 34, Issue 2, April 2015, Pages 181-188. doi.org/10.1016/j.clnu.2014.08.002 Chang M. N, Wei J. Y., Hao L.Y, Ma F.T, Li H.Y, Zhao S.G, Sun P. Effects of different types of zinc supplement on the growth, incidence of diarrhea, immune function, and rectal microbiota of newborn dairy calves. Volume 103, Issue 7, July 2020, Pages 6100-6113. doi.org/10.3168/jds.2019-17610 World Health Organization (WHO). (2023). Zinc supplementation in the management of diarrhea. Retrieved from https://www.who.int/teams/maternal-newborn-child-and-adolescent-health-and-ageing/strategies/diseases/diarrhoea/zinc-supplementation Caroff DA, Edelstein PH, Hamilton K, Pegues DA; CDC Prevention Epicenters Program. The Bristol stool scale and its relationship to Clostridium difficile infection. J Clin Microbiol. 2014 Sep;52(9):3437-9. doi: 10.1128/JCM.01303-14. Kodam V. A comparative study of ORS (Oral Rehydration Solution) with probiotics versus ORS with zinc as an adjunct therapy in pediatric acute diarrheal diseases. Perspectives in Medical Research. 2021;9(3):26-9. doi:10.47799/pimr.0903.07. Ahmadipour S, Mohsenzadeh A, Alimadadi H, Salehnia M, Fallahi A. Treating Viral Diarrhea in Children by Probiotic and Zinc Supplements. Pediatr Gastroenterol Hepatol Nutr. 2019 Mar;22(2):162-170. doi: 10.5223/pghn.2019.22.2.162. Huang R, Xing HY, Liu HJ, Chen ZF, Tang BB. Efficacy of probiotics in the treatment of acute diarrhea in children: a systematic review and meta-analysis of clinical trials. Transl Pediatr. 2021 Dec;10(12):3248-3260. doi: 10.21037/tp-21-511. Cai J, Zhao C, Du Y, Zhang Y, Zhao M, Zhao Q. Comparative efficacy and tolerability of probiotics for antibiotic-associated diarrhea: Systematic review with network meta-analysis. United European Gastroenterol J. 2018 Mar;6(2):169-180. doi: 10.1177/2050640617736987. Azim MA, Doza B, Iqbal S, Chowdhury F, Biswas SK. Comparative Evaluation on the Effect of Zinc-Probiotic and Zinc Therapy in Pediatric Acute Gastroenteritis. Chattagram Maa-O-Shishu Hospital Medical College Journal. 2020;19(1):74-7. doi:10.3329/cmoshmcj.v19i1.48809. Taee N, Anbari K, Pazhouhanfar R. Acute Diarrhea Admitted Children Clinical Trial Zinc Supplementation. JSSU 2013; 20 (5) :547-555. URL: http://jssu.ssu.ac.ir/article-1-2219-fa.html Zarinfar N, Sarmadian H, Esmaili A. Effect of probiotic preparation in preventing antibiotic associated diarrhea and colitis: a Clinical trial. BPUMS. 2014;17(3):368-76. URL: http://ismj.bpums.ac.ir/article-1-549-en.html Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6295667","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":451047655,"identity":"bf93831d-d182-4ff2-95e4-36b7de84d67e","order_by":0,"name":"Mohammad Bagher Rahmati","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIiWNgGAWjYDACCQYGZhDNxt4AJA0siNciwcZzAKRFggQtDBIJUC4hoDu79+Hnwhy7Oj7J51c3/CiQYOBv707Aq8XsznFj6ZnbkiXYpHPKbvYAHSZx5uwG/FpupDFI825jBmlJu8ED1GIgkUtQC/Nv3m31EmySZ9Ju/iFSCxvQlsMSbBLsx24TZ8udY2zWvNuOS7bx5LDdljGQ4CHsl9ttzLd5t1Xzy7cff3bzzR8bOf72XvxakACPAZgkVjkIsD8gRfUoGAWjYBSMIAAAHFlAWSmZR10AAAAASUVORK5CYII=","orcid":"","institution":"Hormozgan University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Mohammad","middleName":"Bagher","lastName":"Rahmati","suffix":""},{"id":451047656,"identity":"19c1b4c3-4986-45d9-a0eb-72346ca54638","order_by":1,"name":"Razieh khodadadzade","email":"","orcid":"","institution":"Hormozgan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Razieh","middleName":"","lastName":"khodadadzade","suffix":""},{"id":451047657,"identity":"b4bf2e87-c9ef-4e82-aa00-0069393bb697","order_by":2,"name":"Mehran Ahmadi","email":"","orcid":"","institution":"Hormozgan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mehran","middleName":"","lastName":"Ahmadi","suffix":""},{"id":451047658,"identity":"1ff4b2e4-824a-4d5c-846c-49a3a91d796c","order_by":3,"name":"Saeed Hoseini teshnizi","email":"","orcid":"","institution":"Hormozgan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Saeed","middleName":"Hoseini","lastName":"teshnizi","suffix":""}],"badges":[],"createdAt":"2025-03-24 13:08:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6295667/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6295667/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82171893,"identity":"dab597e0-f0ea-493d-a03f-1dd32edb8398","added_by":"auto","created_at":"2025-05-07 10:12:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":796343,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6295667/v1/7f462729-72a1-48f8-a46b-6f68ee693287.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Localized Impact of Zinc and Probiotics on Antibiotic-Associated Diarrhea in Children: A Perspective from Southern Iran","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eOver the past two decades, numerous studies have elucidated the clinical benefits and safety profiles of a diverse array of probiotics in the prevention and management of gastrointestinal diseases (1,2,3). The use of probiotics as preventive interventions against antibiotic-associated diarrhea (AAD) in pediatric populations has gained considerable traction. AAD is a prevalent adverse effect associated with antibiotic therapy, leading to significant discomfort and complications (4). Specifically, two probiotic strains, Lactobacillus rhamnosus GG and Saccharomyces boulardii, are recommended for the prevention of AAD in children (5). Lactobacillus rhamnosus GG has demonstrated efficacy in reducing both the incidence and duration of AAD among pediatric patients. A previous study indicated that children administered Lactobacillus rhamnosus GG exhibited a significantly lower risk of developing AAD compared to those receiving a placebo (6). Similarly, Saccharomyces boulardii has been identified as another effective probiotic strain for preventing AAD in children (6,8). Regarding dosage, clinical trials have reported that a higher dose range of 5–40 billion colony-forming units per day is associated with optimal efficacy (6). While probiotics are typically regarded as safe for healthy children, it is important to note that rare but serious adverse events have been documented in severely debilitated or immunocompromised pediatric populations (7). In conclusion, probiotics—specifically Lactobacillus rhamnosus GG and Saccharomyces boulardii—have shown effectiveness in preventing antibiotic-associated diarrhea among children (5).\u003c/p\u003e\n\u003cp\u003eZinc supplementation has demonstrated promising outcomes in the prevention and treatment of antibiotic-associated diarrhea (AAD) in pediatric populations (9). AAD is a prevalent adverse effect associated with antibiotic use, and numerous studies have investigated the role of zinc in mitigating the severity and duration of diarrhea (10). Zinc is an essential micronutrient that plays critical roles in immune response, cellular proliferation, and protein synthesis. Research indicates that zinc enhances the absorption of water and electrolytes in the intestines, contributing to a reduction in both the duration and severity of diarrhea (11). Furthermore, zinc supplementation has been shown to prevent subsequent infections for 2 to 3 months post-administration. The acceptability of zinc supplementation among both children and caregivers is generally high, and its efficacy appears to be consistent regardless of the specific zinc salt used (e.g., zinc sulfate, zinc acetate, or zinc gluconate) (12).\u003c/p\u003e"},{"header":"2. Objectives","content":"\u003cp\u003eThe objective of this study was to evaluate and compare the effects of zinc and probiotics on children aged 3 months to 12 years diagnosed with antibiotic-associated diarrhea (AAD) in southern Iran. While zinc supplementation and probiotics have shown promising outcomes in managing diarrhea, further research is necessary to determine their efficacy, particularly in the prevention and treatment of AAD in pediatric populations.\u003c/p\u003e"},{"header":"3. Materials and methods","content":"\n\u003ch3\u003e3,1. Study Design\u003c/h3\u003e\n\u003cp\u003eThe study included a zinc group, a probiotics group, and a control group. The zinc group received oral zinc supplementation, specifically 2.5 ml every 12 hours for children under 1 year of age and 5 ml every 12 hours for older children. The probiotics group received one sachet of KidiLact daily, which contained Lactobacillus rhamnosus, Lactobacillus reuteri, Bifidobacterium infantis, and other strains, totaling 5\u0026nbsp;billion CFU. The control group received the standard antibiotic regimen without any additional supplementation.\u003c/p\u003e \u003cp\u003eInterventions commenced within 24 hours of antibiotic initiation and continued for seven days. Antibiotic-associated diarrhea (AAD) was defined as the occurrence of three or more loose stools per day for two consecutive days during or within two weeks of antibiotic use. The Bristol stool scale was employed to classify stool consistency. The incidence of AAD was assessed and compared among the three groups, along with the evaluation of other parameters such as hospitalization and treatment\u0026thinsp;\u0026lt;\u0026thinsp;1 year and 5 ml every 12 hours for older children; the probiotics group received 1 sachet of KidiLact daily (containing Lactobacillus rhamnosus, Lactobacillus reuteri, Bifidobacterium infantis, and other strains, CFU: 5\u0026nbsp;billion).; and the control group received Standard antibiotic regimen without additional supplementation. Interventions started within 24 hours of antibiotic initiation and continued for seven days. AAD was defined as three or more loose stools per day for two consecutive days during or within two weeks of antibiotic use. The Bristol stool scale was used to classify stool consistency(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The incidence of AAD was assessed and compared among the three groups.\u003c/p\u003e\n\u003ch3\u003e3,2. Data collection and statistical analysis\u003c/h3\u003e\n\u003cp\u003eAfter the desired information was collected, it was entered into SPSS software version 26 and subsequently analyzed using descriptive statistics. Chi-square tests and Fisher's exact tests were employed to compare qualitative variables between the study groups. Due to the non-normality of the distribution of quantitative variables, as indicated by the Kolmogorov‒Smirnov test, the Kruskal‒Wallis and Mann‒Whitney tests were utilized to compare quantitative variables across groups. Additionally, logistic regression was applied to identify the factors influencing the incidence of AAD.\u003c/p\u003e\n\u003ch3\u003e3,3. Ethical considerations\u003c/h3\u003e\n\u003cp\u003e This study was conducted in accordance with the tenets of the Declaration of Helsinki and was ethically approved by the Ethics Committee of Hormozgan University of Medical Sciences (Approval ID: IR.HUMS.REC.1399.579). Informed consent was obtained from the children and their parents. Clinical trial number is not applicable.\u003c/p\u003e"},{"header":"4. Results","content":"\u003cp\u003eIn this study, a total of 165 children aged between 3 months and 12 years were investigated. The participants had an average age of 45.65\u0026thinsp;\u0026plusmn;\u0026thinsp;41.46 months(Table\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Among the total sample, 84 (50.9%) were boys, and 81 (49.1%) were girls(Table\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). AAD incidence was 12.7% in the zinc group, 9.1% in the probiotic group, and 10.9% in the control group (P\u0026thinsp;=\u0026thinsp;0.829). Hospitalization and treatment durations were significantly shorter in the probiotic group than in the zinc group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e,\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Ampicillin consumption was observed in 16.4% of the probiotics group, 3.6% of the control group, and 1.8% of the zinc group (P\u0026thinsp;=\u0026thinsp;0.013). Additionally, vancomycin consumption was observed in 10.9% of the control group and 7.3% of the zinc group, whereas no patients in the probiotics group received vancomycin (P\u0026thinsp;=\u0026thinsp;0.037)Table\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. No significant differences were found among the groups in terms of the consumption of ceftriaxone, meropenem, cefotaxime, or clindamycin. There was no significant association between AAD and age, sex, hospital length of stay, type of antibiotic, or patient grouping.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of age between study groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eControl(55 persons) (IQR)*\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eProbiotic(55persons) (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eZinc(55 persons) (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (months)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(96\u0026ndash;19) 41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(42\u0026ndash;6) 20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(80\u0026ndash;14) 40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e* IQR، interquartile range\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of gender between study groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl(55 persons) %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProbiotic(55 persons) %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eZinc(55 persons) %\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (5/45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (5/54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (7/52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e601/0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (5/54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (5/45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (3/47)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of the incidence of diarrhea between study groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDiarrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl(55 persons) %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProbiotic(55 persons) %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eZinc(55 persons) %\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (1/89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (9/90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48 (3/87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e829/0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (9/10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (1/9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (7/12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of hospital stay and treatment duration between study groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c7\" namest=\"c6\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl(55 persons) (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProbiotic(55 persons) (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eZinc(55 persons) (IQR)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e001/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003eHospital stay (day)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e001/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003eTreatment Time(day)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eP-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eGroups\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eAntibiotic\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eControl(55 persons) %\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003eProbiotic(55 persons) %\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u003cb\u003eZinc(55 persons) %\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e171/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (5/85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e46 (6/83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e52 (5/94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eCeftriaxon\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e013/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (6/3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e9 (4/16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1 (8/1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eAmpicillin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e037/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (9/10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e4 (3/7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eVancomycin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e128/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (3/7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1 (8/1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eMeropenem\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e117/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (3/7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e9 (4/16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e3 (5/5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eCefotaxim\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e178/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (5/14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e6 (9/10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e13 (6/23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eClindamycin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of antibiotic type between study groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdjusted OR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCrude OR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003evariable\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e466/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(009/1\u0026ndash;981/0) 995/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e635/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(010/1\u0026ndash;985/0) 997/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e313/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(641/1\u0026ndash;213/0) 591/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e362/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(709/1\u0026ndash;231/0) 628/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eControl\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eGroups\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e916/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(544/3\u0026ndash;321/0) 067/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e768/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(802/3\u0026ndash;373/0) 191/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eZinc\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e501/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(385/2\u0026ndash;169/0) 635/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e751/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(852/2\u0026ndash;234/0) 817/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eProbiotic\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e000/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(؟ \u0026minus;\u0026thinsp;0) 158/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e382/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(069/20\u0026ndash;317/0) 523/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eCeftriaxon\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u003cb\u003eAntibiotic\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e999/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(؟ \u0026minus;\u0026thinsp;0) 6/189797070\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e767/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(988/5\u0026ndash;088/0) 727/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eampicillin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e675/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(641/25\u0026ndash;122/0) 771/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e924/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(564/7\u0026ndash;108/0) 902/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eVancomycin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e000/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(0\u0026ndash;0) 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e999/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(0\u0026ndash;0) 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eMeropenem\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e000/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(0\u0026ndash;0) 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e536/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(170/4\u0026ndash;064/0) 518/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eCefotaxim\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e975/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(194/4\u0026ndash;250/0) 023/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e971/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(816/3\u0026ndash;275/0) 025/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eClindamycin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e714/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(184/1\u0026ndash;781/0) 962/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e881/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(166/1\u0026ndash;836/0) 987/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u003cb\u003eHospital stay\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"5. Discussion","content":"\u003cp\u003eThe present study observed that probiotic supplementation was associated with a lower incidence of AAD and reduced hospitalization and treatment durations compared to zinc; however, these differences did not reach statistical significance. These findings contrast with prior studies that reported zinc as more effective in accelerating diarrhea recovery (14, 15). This discrepancy may be attributed to contextual factors in Southern Iran, including regional dietary patterns, healthcare practices, and the specific multi-strain probiotic formulation utilized in this trial. The inclusion of diverse bacterial strains in the probiotic intervention (e.g., Lactobacillus and Bifidobacterium species) may have enhanced its efficacy, consistent with evidence suggesting that synergistic probiotic combinations yield broader therapeutic effects than single strains (16).\u003c/p\u003e\n\u003cp\u003eThe comparative effectiveness of zinc and probiotics remains a topic of ongoing debate. Cai J et al. (17) assessed the efficacy of zinc, probiotics, and their combination in children with AAD, concluding that the combined regimen was more effective than monotherapies\u0026mdash;an assertion that contrasts with the findings of the current study. Similarly, Azim et al. (18) demonstrated that the combination of zinc and probiotics was more effective in reducing the severity of acute gastroenteritis compared to zinc alone. Discrepancies in study design, including variations in inclusion criteria (such as diarrhea etiology and patient demographics), differing zinc dosage forms (e.g., sulfate versus acetate), and diverse probiotic compositions likely contribute to these conflicting results. Additionally, the objectives of earlier studies\u0026mdash;whether aimed at diarrhea prevention or treatment\u0026mdash;may influence the observed outcomes. For example, Tai et al. (19) found that zinc supplementation shortened the duration of AAD in hospitalized children but did not affect disease severity, whereas Zarin Far et al. (20) reported that Lactobacillus probiotics did not reduce the incidence of AAD but alleviated symptoms of colitis. This heterogeneity highlights the necessity of standardizing interventions and outcomes in future research endeavors.\u003c/p\u003e\n\u003cp\u003eNotably, neither zinc nor probiotics in this study significantly reduced hospitalization or treatment duration compared to the control group. This finding contrasts with the conclusions of Huang et al.\u0026rsquo;s meta-analysis (16), which indicated that probiotics effectively shortened diarrhea duration and hospitalization. The null effect observed in this study may reflect regional differences in baseline microbiota, variations in antibiotic prescribing practices, or differences in pathogen prevalence. Furthermore, the relatively small sample size and the non-uniform probiotic formulations across studies complicate direct comparisons.\u003c/p\u003e\n\u003cp\u003eEmerging evidence suggests that combination therapies may offer synergistic benefits. Xiang et al. (9) reported that the administration of zinc in conjunction with probiotics was more effective than probiotics administered alone in managing pneumonia-related antibiotic-associated diarrhea (AAD). Additionally, Hassan et al. (16) and Azim et al. (18) both emphasized the superiority of dual therapy. These findings imply that zinc and probiotics may target distinct biological pathways\u0026mdash;zinc enhances intestinal immunity while probiotics restore microbial balance\u0026mdash;thereby justifying further exploration of their combined use.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe present study underscores the potential efficacy of multi-strain probiotics in managing AAD while emphasizing the need for larger, context-specific trials to address inconsistencies in prior research. Future investigations should include a combination therapy arm (zinc plus probiotics) alongside monotherapy and control groups. Standardizing probiotic strains, zinc formulations, and outcome measures will enhance comparability across diverse populations. Additionally, research should stratify results according to the etiology of diarrhea, as pathogen-specific responses may influence treatment efficacy. Until conclusive evidence is obtained, clinical decision-making should consider regional practices, patient demographics, and available formulations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003eClinicalTrials.gov Identifier: NCT06665503, 2024-10-29.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate:\u0026nbsp;\u003c/strong\u003eThis study was conducted in accordance with ethical guidelines and received approval from the Hormozgan University Ethics Committee (Approval ID: IR.HUMS.REC.1399.579).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u0026nbsp;\u003c/strong\u003eAll authors consent to the publication of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Material:\u0026nbsp;\u003c/strong\u003eThe datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u0026nbsp;\u003c/strong\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research received no specific grant from any funding agency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Contributions:\u0026nbsp;\u003c/strong\u003eM.B.R., S.H.T., and M.A. wrote the main manuscript text. M.B.R. and R.K. collected data. S.H.T. performed the analysis and interpretation. M.B.R. and M.A. edited the manuscript. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eWe thank the investigators, coordinators, and patients who participated in this study, as well as the Clinical Research Development Unit (CRDU) of Bandar Abbas Pediatric Hospital.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eHill C, Guarner F, Reid G, Gibson GR, Merenstein DJ, Pot B, Morelli L, Canani RB, Flint HJ, Salminen S, Calder PC, Sanders ME. Expert consensus document. The International Scientific Association for Probiotics and Prebiotics consensus statement on the scope and appropriate use of the term probiotic. Nat Rev Gastroenterol Hepatol. 2014 Aug;11(8):506-14. doi: 10.1038/nrgastro.2014.66.\u003c/li\u003e\n \u003cli\u003eSanklecha M, Verma L, Pai U, Mishra S, Maqsood S, Birla A. Lactobacillus rhamnosus GG Evaluation in Acute Diarrhea (LEAD): An Observational Study. Cureus. 2022 Apr 29;14(4):e24594. doi: 10.7759/cureus.24594.\u003c/li\u003e\n \u003cli\u003eSzajewska H, Urbańska M, Chmielewska A, Weizman Z, Shamir R. Meta-analysis: Lactobacillus reuteri strain DSM 17938 (and the original strain ATCC 55730) for treating acute gastroenteritis in children. Benef Microbes. 2014 Sep;5(3):285-93. doi: 10.3920/BM2013.0056.\u003c/li\u003e\n \u003cli\u003eKopacz K, Phadtare S. Probiotics for the Prevention of Antibiotic-Associated Diarrhea. Healthcare (Basel). 2022 Aug 2;10(8):1450. doi: 10.3390/healthcare10081450.\u003c/li\u003e\n \u003cli\u003eGoldenberg JZ, Lytvyn L, Steurich J, Parkin P, Mahant S, Johnston BC. Probiotics for the prevention of pediatric antibiotic-associated diarrhea. Cochrane Database Syst Rev. 2015 Dec 22;(12):CD004827. doi: 10.1002/14651858.CD004827.pub4. Update in: Cochrane Database Syst Rev. 2019 Apr 30;4:CD004827. doi: 10.1002/14651858.CD004827.\u003c/li\u003e\n \u003cli\u003eHempel S, Newberry SJ, Maher AR, Wang Z, Miles JN, Shanman R, Johnsen B, Shekelle PG. Probiotics for the prevention and treatment of antibiotic-associated diarrhea: a systematic review and meta-analysis. JAMA. 2012 May 9;307(18):1959-69. doi: 10.1001/jama.2012.3507.\u003c/li\u003e\n \u003cli\u003eSzajewska H, Kotowska M, Mrukowicz JZ, Armańska M, Mikołajczyk W. Efficacy of Lactobacillus GG in prevention of nosocomial diarrhea in infants. J Pediatr. 2001 Mar;138(3):361-5. doi: 10.1067/mpd.2001.111321.\u003c/li\u003e\n \u003cli\u003eWan CM, Yu H, Liu G, Xu HM, Mao ZQ, Xu Y, Jin Y, Luo RP, Wang WJ, Fang F. [A multicenter randomized controlled study of Saccharomyces boulardii in the prevention of antibiotic-associated diarrhea in infants and young children]. Zhonghua Er Ke Za Zhi. 2017 May 4;55(5):349-354. Chinese. doi: 10.3760/cma.j.issn.0578-1310.2017.05.008.\u003c/li\u003e\n \u003cli\u003eXiang R, Tang Q, Chen XQ, Li MY, Yang MX, Yun X, Huang L, Shan QW. Effects of Zinc Combined with Probiotics on Antibiotic-associated Diarrhea Secondary to Childhood Pneumonia. J Trop Pediatr. 2019 Oct 1;65(5):421-426. doi: 10.1093/tropej/fmy069.\u003c/li\u003e\n \u003cli\u003eSelma C. Liberato, Gurmeet Singh, Kim Mulholland. Inc. supplementation in young children: A review of the literature focusing on diarrhea prevention and treatment. Volume 34, Issue 2, April 2015, Pages 181-188. doi.org/10.1016/j.clnu.2014.08.002\u003c/li\u003e\n \u003cli\u003eChang M. N, Wei J. Y., Hao L.Y, Ma F.T, Li H.Y, Zhao S.G, Sun P. Effects of different types of zinc supplement on the growth, incidence of diarrhea, immune function, and rectal microbiota of newborn dairy calves. Volume 103, Issue 7, July 2020, Pages 6100-6113. doi.org/10.3168/jds.2019-17610\u003c/li\u003e\n \u003cli\u003eWorld Health Organization (WHO). (2023). Zinc supplementation in the management of diarrhea. Retrieved from https://www.who.int/teams/maternal-newborn-child-and-adolescent-health-and-ageing/strategies/diseases/diarrhoea/zinc-supplementation\u003c/li\u003e\n \u003cli\u003eCaroff DA, Edelstein PH, Hamilton K, Pegues DA; CDC Prevention Epicenters Program. The Bristol stool scale and its relationship to Clostridium difficile infection. J Clin Microbiol. 2014 Sep;52(9):3437-9. doi: 10.1128/JCM.01303-14.\u003c/li\u003e\n \u003cli\u003eKodam V. A comparative study of ORS (Oral Rehydration Solution) with probiotics versus ORS with zinc as an adjunct therapy in pediatric acute diarrheal diseases. Perspectives in Medical Research. 2021;9(3):26-9. doi:10.47799/pimr.0903.07.\u003c/li\u003e\n \u003cli\u003eAhmadipour S, Mohsenzadeh A, Alimadadi H, Salehnia M, Fallahi A. Treating Viral Diarrhea in Children by Probiotic and Zinc Supplements. Pediatr Gastroenterol Hepatol Nutr. 2019 Mar;22(2):162-170. doi: 10.5223/pghn.2019.22.2.162.\u003c/li\u003e\n \u003cli\u003eHuang R, Xing HY, Liu HJ, Chen ZF, Tang BB. Efficacy of probiotics in the treatment of acute diarrhea in children: a systematic review and meta-analysis of clinical trials. Transl Pediatr. 2021 Dec;10(12):3248-3260. doi: 10.21037/tp-21-511.\u003c/li\u003e\n \u003cli\u003eCai J, Zhao C, Du Y, Zhang Y, Zhao M, Zhao Q. Comparative efficacy and tolerability of probiotics for antibiotic-associated diarrhea: Systematic review with network meta-analysis. United European Gastroenterol J. 2018 Mar;6(2):169-180. doi: 10.1177/2050640617736987.\u003c/li\u003e\n \u003cli\u003eAzim MA, Doza B, Iqbal S, Chowdhury F, Biswas SK. Comparative Evaluation on the Effect of Zinc-Probiotic and Zinc Therapy in Pediatric Acute Gastroenteritis. Chattagram Maa-O-Shishu Hospital Medical College Journal. 2020;19(1):74-7. doi:10.3329/cmoshmcj.v19i1.48809.\u003c/li\u003e\n \u003cli\u003eTaee N, Anbari K, Pazhouhanfar R. Acute Diarrhea Admitted Children Clinical Trial Zinc Supplementation. JSSU 2013; 20 (5) :547-555. URL: http://jssu.ssu.ac.ir/article-1-2219-fa.html\u003c/li\u003e\n \u003cli\u003eZarinfar N, Sarmadian H, Esmaili A. Effect of probiotic preparation in preventing antibiotic associated diarrhea and colitis: a Clinical trial. BPUMS. 2014;17(3):368-76. URL: http://ismj.bpums.ac.ir/article-1-549-en.html\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"antibiotic-associated diarrhea, children, zinc, probiotics","lastPublishedDoi":"10.21203/rs.3.rs-6295667/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6295667/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAntibiotic-associated diarrhea (AAD) is a frequently encountered complication that arises from the administration of antimicrobial agents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe aim of this study was to evaluate the efficacy \u0026nbsp;of zinc and probiotics in reducing antibiotic-associated diarrhea (AAD) incidence, hospitalization, and treatment duration..\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients and methods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is a randomized clinical trial involving 165 children referred to Bandar Abbas Children's Hospital, which necessitated antibiotics for any given reason. They were randomly assigned to three groups of equal size, exclusively receiving the standard antibiotic regimen or the zinc and probiotics groups. Age, sex, length of hospital stay, treatment duration, type of antibiotic, and incidence AADwere documented for all patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 165 children who participated in the survey, AAD occurred in 12.7% of the zinc group, 9.1% of the probiotics group, and 10.9% of the control group; however, the difference among the groups was not statistically significant (P=0.829). There was no significant association between AAD and age, sex, hospital length of stay, type of antibiotic, or patient grouping.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite the lower incidence of AAD, duration of hospital stay and duration of treatment in children in the probiotic group, these findings were not statistically significant.\u003c/p\u003e","manuscriptTitle":"Localized Impact of Zinc and Probiotics on Antibiotic-Associated Diarrhea in Children: A Perspective from Southern Iran","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 10:04:29","doi":"10.21203/rs.3.rs-6295667/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-19T07:18:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-18T10:40:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-11T10:43:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"207743535264491534415782889698870232202","date":"2025-05-11T09:50:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-11T05:48:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"185041748136448333406016900970522261346","date":"2025-05-10T06:29:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82199689928267594233645829870030514154","date":"2025-05-02T10:44:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-02T10:22:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-21T14:31:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-21T14:28:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Medicine","date":"2025-03-24T13:02:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6f9fe2e1-0ac1-49d5-a820-e6dadb08571c","owner":[],"postedDate":"May 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-06-02T10:38:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-07 10:04:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6295667","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6295667","identity":"rs-6295667","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}