General Practitioners and Gut Microbiota: Surveying Knowledge and Awareness in Italy

Abstract

Background/Objectives: The role of the intestinal microbiota in gastroenterological diseases has gained increasing relevance in general medicine. The study aimed to evaluate the knowledge and awareness of Italian general practitioners regarding gut microbiota, as well as the clinical applications of probiotics and prebiotics. Methods: The survey research involved 457 Italian general practitioners, who anonymously filled an online structured questionnaire. Results: Most respondents identified antibiotics, diet, gastrointestinal infections, and stress as factors that can modulate the gut microbiota, while a smaller proportion recognized the role of physical activity. A comparable number acknowledged the influence of obesity, smoking, and immunosuppressant drugs. Although most participants correctly defined probiotics, the concept of prebiotics was less widely understood. Probiotics were primarily prescribed for irritable bowel syndrome, suspected dysbiosis, or during antibiotic therapy, and only a portion of physicians reported routinely combining them with prebiotics. The selection of probiotic strains was mainly based on personal experience, while fecal microbiota analysis was seldom used in clinical practice. Conclusions: These findings provide an updated snapshot of current knowledge and practices regarding the microbiota in Italian general medicine and highlight critical gaps, particularly in the understanding of prebiotics and less recognized modulatory factors.

1. Introduction

In recent years, gut microbiota has emerged as a central focus in biomedical research, increasingly recognized for its pivotal role in human health and disease. A growing body of evidence supports the concept that intestinal microbiota is not only essential for maintaining physiological homeostasis but also has a profound influence on the onset, progression, and therapeutic response of a wide range of medical conditions [1,2,3,4]. These conditions encompass, but are not limited to, gastrointestinal diseases, metabolic syndromes, autoimmune disorders, and neuropsychiatric illness [5,6,7,8].

The composition and functionality of the gut microbiota are shaped by a complex interplay of endogenous and exogenous factors, including dietary patterns, pharmacological treatments, aging, genetic predisposition, and the presence of underlying pathologies [9,10,11,12]. These dynamic and mutual interactions contribute to interindividual variability and influence both disease susceptibility and clinical outcomes.

Despite the increasing scientific and clinical interest in this field, current data suggest that knowledge and awareness of gut microbiota-related concepts remain heterogeneous among healthcare professionals. Notable gaps persist concerning the clinical interpretation of microbiome data, the implementation of microbiota-modulating strategies, and the translation of research findings into evidence-based practice [13,14,15].

In this context, general practice constitutes a strategic setting for the prevention and management of microbiota-related conditions. As frontline providers, general practitioners [GPs] are often the first point of contact in the healthcare system. They are thus ideally positioned to recognize early signs of dysbiosis and initiate appropriate interventions [16]. Their role is further amplified by the widespread diffusion of microbiota-related content through mainstream media, social networks, and wellness platforms, which has contributed to an increase in patient interest—and, frequently, unrealistic expectations—regarding the influence of the gut microbiome on overall health.

Against this backdrop, GPs are called upon to navigate a complex and evolving informational landscape, providing patients with accurate, evidence-based guidance. Accordingly, the present study aimed to evaluate the level of knowledge within a sample of Italian GPs concerning key clinical aspects of the intestinal microbiota.

2. Results

A total of 457 out of 1735 invited physicians completed the survey, yielding a response rate of 26.3%. Most respondents were under 45 years of age (63.9%), with geographic distribution across North-West (21.2%), North-East (28.2%), Central (13.3%), Southern Italy (28.0%), and the Islands (9.2%), broadly reflecting the national demographic profile of GPs.

More than 75% of participants recognized the impact of antibiotics (95.4%), dietary habits (90.6%), gastrointestinal infections (88.8%), and psychological stress (77.0%) on gut microbiota composition, classified as major factors. Approximately half of the respondents acknowledged the influence of immunosuppressive therapy (64.3%), obesity (59.1%), and cigarette smoking (57.1%), defined as intermediate factors (p < 0.001 vs. major factors). Lower percentages were observed for physical activity (47.3%), insomnia (33.9%), and the use of biological therapies (33.5%), forming the group of minor factors (p < 0.005 vs. intermediate factors). Differences emerged between age groups: younger physicians (<45 years) were significantly more likely than older colleagues to identify smoking (p = 0.001), biological therapies (p = 0.013), insomnia (p = 0.001), stress (p = 0.001), and obesity (p = 0.001) as contributors to intestinal dysbiosis (

Table 1. Factors believed to influence the intestinal microbiota.

Factors	Total [n = 457]	GPs < 45 yrs Old [n = 292]	GPs > 45 yrs Old [n = 165]	p
Major factors
Antibiotics	95.4%	94.5%	97.0%	-
Dietary habits	90.6%	92.8%	86.7%	-
Gastrointestinal infections	88.8%	88.0%	90.3%	-
Stress	77.0%	83.9%	64.8%	0.001
Intermediate factors (p = 0.001 vs. major factors)
Immunosuppressive drugs	64.3	63.0%	66.4%	-
Obesity	59.1%	66.1%	46.7%	0.001
Cigarette smoking	57.1%	63.7%	45.5%	0.001
Minor factors (p = 0.005 vs. intermediate factors)
Physical activity	47.3%	50.0%	42.4%	-
Insomnia	33.9%	41.1%	19.4%	0.001
Biologic drug therapies	33.5%	38.4%	24.8%	0.013

).

Regarding knowledge on probiotics, 39.6% of respondents reported being unaware of the scientific evidence supporting their role and use. Only 14.9% declared general awareness of probiotic-related evidence, while 42.9% had familiarity limited only to specific strains. A minority (2.6%) believed there is no scientific evidence supporting probiotic use. No significant differences were found between age groups.

A total of 82.3% of participants correctly identified the accepted definition of probiotics (“live microorganisms that, when administered in adequate amounts, confer a health benefit on the host”), with no differences between younger and older physicians. However, only 46.0% correctly defined prebiotics (“non-digestible food-derived substances that selectively promote the growth and/or activity of one or more beneficial bacterial species already present in the gut or co-administered with the prebiotic”), with a significantly lower recognition rate compared to probiotics (p < 0.001). Younger physicians were more likely to select the correct definition of prebiotics compared to their older colleagues (p = 0.020).

Figure 1 illustrates the frequency of probiotic use in various clinical scenarios. Probiotics were most used in cases of suspected microbiota imbalance (87.7%) and in patients with irritable bowel syndrome (IBS) (73.5%) (group 1 conditions). They were also frequently recommended during or after antibiotic therapy (63.5%), after episodes of acute gastroenteritis (57.5%), following Helicobacter pylori (H. pylori) eradication therapy (48.1%), and in patients with inflammatory bowel disease (IBD) (57.5%) (group 2 conditions; p < 0.001 vs. group 1). Indications for probiotic use were considerably lower as a preventive measure, such as cyclic use in colonic diverticulosis (33.9%) or prior to travel to high-risk destinations (24.1%) (group 3 conditions; p < 0.001 vs. group 2). Younger physicians reported more frequent probiotic use in IBS (p = 0.006), after H. pylori therapy (p = 0.011), and during or after antibiotic treatment (p = 0.023).

Prebiotic use was even more variable. A total of 35.0% of participants reported always combining prebiotics with probiotics; 18.0% used them only in patients with severe gastrointestinal symptoms; 33.7% used them during or after antibiotic therapy; and 30.2% used them in IBD patients. Younger physicians were significantly more likely to always prescribe prebiotics in combination with probiotics (p = 0.015).

Probiotic strain selection was primarily based on personal clinical experience and knowledge of product composition (82.3%). Other influencing factors, such as trust in the manufacturer (8.1%), pharmacist recommendation (4.2%), patient experience (3.9%), and product cost (1.5%), played a minor role (all p < 0.001 vs. personal experience). No significant age-related differences were observed.

Only 12.5% of participants reported being unfamiliar with fecal microbiota analysis, with this lack of awareness more common among older physicians (p = 0.004). A minority (8.8%) reported prescribing the investigation, while 58.6% had heard of it but did not use it. Additionally, 10.7% of respondents considered the interpretation of test results too complex for routine use in general practice.

An analysis was conducted to determine whether participants with higher theoretical knowledge of microbiota (defined as those who correctly answered both the probiotic and prebiotic definition questions; n = 180) differed from the rest of the sample (n = 277). This subgroup was more frequently represented by younger physicians (77% vs. 41.2%; p = 0.001).

After adjusting for age as a covariate, only one significant difference remained: those in the high-knowledge group more frequently identified physical activity as a dysbiosis-related factor (p = 0.009). This group also reported higher use of probiotics following H. pylori eradication therapy (p = 0.035) and during or after acute gastroenteritis (p = 0.010).

No significant differences were observed between high- and low-knowledge groups regarding awareness of scientific evidence, strength of recommendations, clinical indications for the use of probiotics and prebiotics, probiotic selection criteria, or knowledge of fecal microbiota testing.

3. Discussion

The results of this survey, conducted among a sample of GPs, indicate a current partial understanding of gut microbiota-related topics, with significant knowledge gaps particularly regarding prebiotics and the identification of key modulatory factors.

The number of respondents and their geographic distribution across various Italian regions support the representativeness of the sample. Although the response rate may appear relatively low, existing literature on survey methodology [17] suggests that response rates have been declining in recent years, especially when the sample is entirely unselected, as in the present investigation.

Regarding the factors influencing gut microbiota composition, respondents correctly identified the roles of antibiotics, diet, gastrointestinal infections, and psychological stress, which is consistent with the current scientific literature [18,19,20]. However, the impact of physical activity on microbial diversity, well established by recent studies [21], was largely underrecognized, even among younger physicians who generally demonstrated greater awareness of additional influencing factors such as smoking, biological therapies, insomnia, stress, and obesity.

Particularly noteworthy is the attention given to the association between microbiota and obesity, in line with an increasing body of evidence linking the gut microbiome to metabolic syndromes [22,23,24,25,26]. Cigarette smoking, too, appears to be associated with obesity via microbiota alterations [27].

Contemporary scientific research evaluates the influence of factors affecting the gut microbiota, such as those examined in this survey, using cohort studies, metagenomic analyses, and controlled clinical trials. These methodologies elucidate how each factor distinctly modulates microbial composition and diversity, with consequential effects on host metabolism, inflammation, and chronic disease risk. For instance, obesity and smoking are linked to reduced microbial diversity and a pro-inflammatory milieu, whereas physical activity and stress reduction foster eubiosis; early-life antibiotic exposure is associated with persistent dysbiosis and an elevated risk of obesity and metabolic disorders [28,29].

A significant proportion of participants reported having only limited knowledge of the scientific evidence on probiotics and exhibited considerable confusion, particularly in defining prebiotics. These findings are consistent with data from earlier studies [15], including those involving other healthcare professionals [13], highlighting the need to implement education on these topics, given their frequent application in everyday clinical practice. Standard definitions of probiotics and prebiotics are outlined by the International Scientific Association for Probiotics and Prebiotics [30], and an accurate understanding of these definitions through specific training activity is essential for appropriate clinical use.

Despite the gaps, the reported clinical use of probiotics and prebiotics by participants appears broadly aligned with existing scientific evidence. Probiotics are most employed in cases of suspected intestinal dysbiosis. However, the criteria adopted for this clinical suspicion remain undefined in the absence of standardized diagnostic tests. The high rate of probiotic use for IBS is clearly supported by recent meta-analyses [31] and Italian guidelines [32], which, despite acknowledging the low level of evidence, endorse their use for overall symptom management or abdominal pain. Thus, a thorough patient evaluation using the Rome IV Criteria [33] is essential for the accurate diagnosis of IBS and other functional syndromes, enabling appropriate guideline-based therapeutic approaches and personalized treatments. This prescribing behavior has also been observed in similar studies conducted in other European countries with comparably sized cohorts [15].

Conversely, the use of probiotics in the incidental finding of colonic diverticulosis was infrequent, consistent with current recommendations that lack robust scientific support. The 2014 Italian Consensus Conference [34] concluded that the available data were insufficient to justify the use of probiotics in diverticular disease management. This has been confirmed by subsequent systematic reviews [35] and reaffirmed by the most recent Italian guidelines [36], which emphasize the absence of conclusive evidence.

Similarly, limited interest was reported in the use of probiotics for the prevention of traveler’s diarrhea, despite emerging data that are in line with potential prophylactic benefit [37]. Use in the context of acute gastroenteritis or following antibiotic therapy, including H. pylori eradication, was of intermediate frequency, with 50–66% of participants showing a favorable response. This rate remains significantly lower than that reported for IBS. Although large, low-bias trials exist, the efficacy of probiotics in reducing gastroenteritis symptoms remains uncertain [38]. Furthermore, current evidence does not support the concept that probiotics restore microbiota to its pre-antibiotic state [39]. Nevertheless, probiotic administration following antibiotic therapy remains among the most adopted strategies by both GPs and gastroenterologists [14].

Regarding H. pylori treatment, probiotic supplementation appears to confer additional benefit, largely attributable to improved patient adherence [40], although potential long-term adverse effects have also been hypothesized [41]. More than half of the respondents declared using probiotics in IBD, even though recent international guidelines do not support this indication [42]. However, specific probiotics may be effective for inducing clinical remission and preventing relapses in ulcerative colitis and pouchitis [43,44,45].

Prebiotic use also displayed age-related differences, with younger physicians more inclined to combine them with probiotics. This attitude aligns with the concept of symbiotic, yet the actual role of prebiotic supplementation remains poorly understood among respondents [30]. Despite over 30% of participants expressing interest in using prebiotics in IBD, current international guidelines do not recommend their use [42,43,44].

A relevant finding pertains to the criteria used for probiotic selection: most respondents relied on personal clinical experience, with no significant differences between age groups. This reflects the ongoing uncertainty in the literature regarding the specific utility of individual bacterial strains, largely due to the heterogeneity of available studies [32]. In this context, GPs assert clinical autonomy in therapeutic decision-making, with minimal delegation to patients or other healthcare professionals, thus underscoring a responsible approach to treatment management.

The application of combined interventions, including probiotics, prebiotics, dietary modification, physical activity, pharmacological agents, and, in selected cases, fecal microbiota transplantation, is increasingly tailored to individual clinical profiles and risk factors. This personalized approach has shown promising outcomes, particularly in the management of obesity and metabolic syndrome associated with dysbiosis. The efficacy of such multimodal strategies is supported by studies demonstrating improvements in metabolic parameters, gut microbiota composition, and both psychiatric and somatic symptoms [46,47].

Fecal microbiota analysis is emerging as a potential diagnostic tool, although its interpretation remains complex and demands further training [48]. A recent consensus conference concluded that there is currently insufficient evidence to recommend routine microbiome testing in clinical practice, which should instead be guided by dedicated research [49].

Survey results show that younger physicians are more likely to use probiotics across various clinical scenarios than their older colleagues. This may reflect a greater interest among newer generations in the evolving conceptual framework associated with microbiota research. Comparing these findings with those from a 2023 study involving the Italian Association of Young Gastroenterologists and Endoscopists [50] is particularly revealing: only 68% of them provided a correct definition of probiotics, compared to 88% of young GPs in our study. Additionally, 31% of them reported using probiotics following H. pylori treatment versus 53% of young GPs. Probiotic use in IBS and diverticulosis was reported by 77% and 31% of gastroenterologists, and 78% and 33% of GPs, respectively. These findings suggest that the prescribing habits of younger GPs are at least as aligned with Italian and international recommendations as those of their specialist counterparts.

To explore whether awareness of microbiota concepts influenced clinical behavior, participants were arbitrarily divided into two groups according to the accuracy of their definitions of probiotics and prebiotics. While younger physicians were more frequently represented in the group providing correct responses, no substantial differences in clinical behavior were observed. This may be attributed to the limited sample size, which represents a major limitation of this study, although numerically comparable with previous studies [13,15], and warrants larger-scale investigation. We acknowledge that the voluntary participation and digital dissemination of the survey may have introduced a selection bias, potentially favoring physicians with a greater interest in gut microbiota-related topics. This could have led to a modest overestimation of knowledge and awareness levels. However, this limitation is common in similar surveys targeting healthcare professionals and highlights the need for future studies using stratified or randomized sampling methods.

Furthermore, the survey was intentionally designed with a limited number of questions to encourage participation, and participant selection was unfiltered, as is typical in comparable research [15].

4. Materials and Methods

A brief questionnaire was administered to a total of 1735 GPs operating across ten Italian regions. The survey was delivered in digital format, accessible via a dedicated anonymous link. Informed consent was required to access the questionnaire. The study was conducted in early 2025 and extended over a one-month period across Italy. No predetermined time limit was imposed for survey completion; nonetheless, our simulations estimated an average completion time of only a few minutes. To ensure maximum anonymity, participants were only asked to indicate their age group and geographical area of practice (North, Center, South, or Islands).

The questionnaire, developed by the authors, consisted of both single-choice and multiple-choice items (

Table 2. Questionnaire.

What is your age?	<35 yrs; 35–44 yrs; 45–54 yrs; 55–64 yrs; >64 yrs
In which region of Italy do you work?	North-East; North-West; Center; South; Islands
Which of the following factors do you believe can cause intestinal dysbiosis, defined as an imbalance in the gut bacterial flora? (Multiple answers allowed)	○ antibiotic use ○ cigarette smoking ○ physical activity ○ treatment with biological drugs ○ insomnia ○ dietary habits ○ gastrointestinal infections ○ treatment with immunosuppressive drugs ○ stress ○ obesity
Are you familiar with the scientific evidence and current recommendations regarding the use of probiotics? (Single answer)	○ Yes ○ No ○ Only for certain probiotics ○ There is no evidence in the literature
Which of the following best defines probiotics? (Single answer)	○ Inactivated bacteria that, if administered in adequate amounts, provide a health benefit to the patient ○ Live microorganisms that provide a health benefit to the patient ○ Live microorganisms that, if administered in adequate amounts, provide a health benefit to the host ○ Lactic acid bacteria capable of stably colonizing all segments of the colon
Which of the following best defines prebiotics? (Single answer)	○ Digestible food-derived substances that promote the growth and activity of one or more bacteria already present in the intestinal tract or taken together with the prebiotic ○ Non-digestible food-derived substances that selectively promote the growth and activity of one or more bacteria already present in the intestinal tract or taken together with the prebiotic ○ Digestible food-derived substances that, when taken in adequate amounts, promote the growth and activity of one or more bacteria already present in the intestinal tract ○ Non-digestible food-derived substances that promote the growth and activity of one or more bacteria, taken together with the prebiotic
In your opinion, in which clinical conditions is the use of probiotics indicated? (Multiple answers allowed)	○ In patients with irritable bowel syndrome ○ In patients with Inflammatory Bowel Disease ○ After eradication therapy for Helicobacter pylori ○ In all situations involving an alteration of the microbiota ○ During and after acute gastroenteritis ○ During or after antibiotic therapy ○ Before an “exotic” trip
In your opinion, in which clinical conditions is the use of prebiotics indicated? (Multiple answers allowed)	○ During or after antibiotic therapy ○ Always when I decide to prescribe probiotics ○ In patients with Inflammatory Bowel Disease ○ When I choose to use probiotic therapy in patients with severe intestinal symptoms
Which criteria do you consider when prescribing probiotics? (Multiple answers allowed)	○ The knowledge of the product’s formulation ○ I choose the least expensive product ○ Trust in the manufacturing company ○ I let the patient choose ○ I leave the choice to the pharmacist
Are you familiar with the fecal microbiota test? (Single answer)	○ I’ve heard of it, but I’ve never prescribed it ○ I don’t believe there is sufficient evidence to justify its use ○ I prescribe it to patients who I believe may benefit from it ○ I’m not familiar with it ○ I would prescribe it, but interpreting the results is too complex

). The survey explored GPs’ perceptions of the factors influencing the gut microbiota, their awareness of scientific evidence regarding the use of probiotics and prebiotics, prescription habits, and the application of fecal tests for microbiota analysis.

All responses were collected in a dedicated database, with strict preservation of respondent anonymity. Results were reported as the percentage of correct answers out of the total number of responses. To assess associations between categorical variables, the two-tailed Fisher’s exact test was employed. Where appropriate, stratified analyses were conducted using the Mantel–Haenszel test to control for potential confounding factors such as age. A p-value < 0.05 was considered statistically significant.

According to current Italian regulations, anonymous surveys involving physicians that do not utilize patient data or clinical records do not require ethical approval by an institutional review board. The study was conducted in accordance with the principles outlined in the Declaration of Helsinki.

5. Conclusions

The gut microbiome can have a critical role in maintaining health and in mediating disease. This survey provides an updated overview of Italian GPs’ knowledge and prescribing habits related to the gut microbiota. The findings highlight critical areas, particularly regarding the understanding of prebiotics and the recognition of less commonly known modulatory factors, indicating the need for specific and up-to-date educational initiatives. These knowledge gaps may limit the effective integration of emerging scientific insights into routine clinical practice.

To bridge the identified educational gap, we propose the implementation of integrated training initiatives that actively involve both general practitioners and specialists. A blended learning model may prove particularly effective: essential preparatory materials (e.g., ISAPP consensus documents, national guidelines) could be distributed in advance, followed by interactive webinars or workshops centered on clinical case discussions. In addition, short educational video-pills, digital toolkits, and structured e-learning courses with formal certification could support a more consistent and evidence-based integration of microbiota-related strategies into general practice. To maximize their impact, these resources should be disseminated through institutional channels, including scientific societies and continuous medical education platforms.

By identifying these discrepancies, the present study points to the development of targeted educational programs and suggests the need for evidence-based guidelines in primary care. Further observational studies and structured training will be essential to enhance awareness and promote the appropriate clinical use of microbiota modulation strategies among GPs.