Probiotics is traditionally used as a term to describe the use of live microorganisms as food supplements that benefit the host by improving the intestinal microbial balance (
50). Probiotics are used as an alternative therapy for treatment of infectious gastroenteritis or in the prevention and cure of antibiotic-associated diarrhea (AAD), which is a frequent complication of antimicrobial treatment of hospitalized patients (
7,
20,
37).
Lactic acid bacteria of the genera
Lactobacillus and
Bifidobacterium are the most common microorganisms used as probiotics. However, yeasts of the species
Saccharomyces are used as well.
Saccharomyces boulardii, in particular, has been very successful in prevention and treatment of AAD, being especially effective against
Clostridium difficile, the cause of about a third of all AAD cases (
7,
56).
S. boulardii was isolated from fruit in Indochina, and because of its benefits in the treatment of diarrhea, it is now a commercially available alternative remedy in Europe, Africa, and South America (
39,
45) for AAD, acute diarrhea in children, and traveler's diarrhea (
22). Many in vitro and some in vivo studies have suggested that
S. boulardii is able to prevent intestinal infections caused by the adherence or invasion of
C. difficile,
Escherichia coli, and
Candida albicans to the epithelial layer of the gastrointestinal tract (
4,
11,
12). The efficacy of
S. boulardii reported in case studies and in vitro trials (
11) has led to investigations of the mechanisms involved in the probiotic activity of this yeast. Several potential mechanisms of probiotic activity have been suggested, including secretion of proteases or inhibitory proteins, stimulation of immunoglobulin A, acquisition and elimination of secreted toxins, modification of the intestinal mucosa, and direct adherence to the epithelial layer causing competition for colonization sites (
12,
20). However, the mechanisms identified so far do not reflect the full set of interactions of this yeast with the host. For a start, it is unclear whether the probiotic effect of
S. boulardii is related to gut colonization. Administration of a single dose of lyophilized
S. boulardii to gnotobiotic mice resulted in the shedding of yeast cells into the feces for more than 10 days after administration (
49). However, common laboratory strains of
Saccharomyces cerevisiae were rapidly excluded from the gut of normal mice in only a few days or hours, suggesting that the presence of a normal enteric microflora may prevent colonization (
44).
While the probiotic properties of
S. boulardii have been demonstrated over the past 50 years, there is also evidence that it may act as an opportunistic pathogen causing
Saccharomyces fungemia (
39). The cause of these cases has often been identified as infection by the yeast via inserted catheters (
3,
8,
26,
38). However, these incidents have raised concerns regarding the advisability of administering
S. boulardii to immunocompromised patients. As the potential mechanisms of probiotic action include interactions with the immune system as well as the direct stimulation of host tissue, the safety of such treatments for patients whose immune systems are incapacitated would appear in doubt. Therefore, to maximize the benefits of treatment with
S. boulardii as well as to minimize the potential risks, the mechanisms of this yeast's probiotic action need to be identified, and any potential for virulence must be fully investigated.
S. boulardii was initially identified as a separate species of the hemiascomycete genus
Saccharomyces (
40). However, the rapid development of molecular phylogenetics in recent years has led to changes in the classification of many yeast species (
17,
39,
57). Using comparative genomic hybridizations for whole-genome analysis, we concluded that
S. cerevisiae and
S. boulardii are members of the same species (
17). However, we also demonstrated some distinctive features of the
S. boulardii genome with respect to its Ty elements (yeast retrotransposons) and the copy number of genes in its subtelomeric regions (
17). In this paper, we report a number of new findings concerning the genomic and phenotypic characteristics of
S. boulardii that may have an indirect or, indeed, direct bearing on the probiotic effects of this yeast, and we identify potential benefits and risks that may be associated with them.