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We thank Dr Shah for her appreciation of our study and acceptance of our results. We agree that further, well-designed, randomized, controlled trials are needed to confirm our results. A recent study in adults (Am J Gastroenterol 2010 Jun 1 [Epub ahead of print]) and 2 studies in children (Inflamm Bowel Dis 2009;15:760–768; Am J Gastroenterol 2009;104:437–443) do, however, support our results by demonstrating efficacy of VSL#3 in inducing remission in relapsed ulcerative colitis. The patients in these 3 studies are from outside India, indicating that this probiotic should be effective in all patients with ulcerative colitis, including those from the United States.

We would like to emphasize that probiotics is a generic term and hence it is important to keep in mind which specific bacteria or cocktail of bacteria is effective in a specific disease (N Engl J Med 2002;347:1983). Different probiotics cannot be equated, nor used interchangeably. Other than VSL #3, Escherichia coli Nissle (Lancet 1999;354:635–639) and Saccharomyces boulardii (Eur J Gastroenterol Hepatol 2003;15:697–698) have shown some efficacy in controlling a relapse of ulcerative colitis. These studies were, however, limited by their small sample size and short study duration.

The safety of probiotics is another issue. Thus, caution should be exercised while using Saccharomyces boulardii because its use as a probiotic has resulted in fungemia in a number of patients (CID 2005;41:1559–1568).