Probiotics for the prevention of Clostridium difficile-associated diarrhea: a systematic review and meta-analysis.

The Hospital for Sick Children Research Institute, Room 2420, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
Annals of internal medicine (Impact Factor: 16.1). 12/2012; 157(12):878-88.
Source: PubMed

ABSTRACT Antibiotic treatment may disturb the resistance of gastrointestinal flora to colonization. This may result in complications, the most serious of which is Clostridium difficile–associated diarrhea (CDAD).
To assess the efficacy and safety of probiotics for the prevention of CDAD in adults and children receiving antibiotics.
Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, Allied and Complementary Medicine Database, Web of Science, and 12 gray-literature sources.
Randomized, controlled trials including adult or pediatric patients receiving antibiotics that compared any strain or dose of a specified probiotic with placebo or with no treatment control and reported the incidence of CDAD.
Two reviewers independently screened potentially eligible articles; extracted data on populations, interventions, and outcomes; and assessed risk of bias. The Grading of Recommendations Assessment, Development and Evaluation guidelines were used to independently rate overall confidence in effect estimates for each outcome.
Twenty trials including 3818 participants met the eligibility criteria. Probiotics reduced the incidence of CDAD by 66% (pooled relative risk, 0.34 [95% CI, 0.24 to 0.49]; I(2) = 0%). In a population with a 5% incidence of antibiotic-associated CDAD (median control group risk), probiotic prophylaxis would prevent 33 episodes (CI, 25 to 38 episodes) per 1000 persons. Of probiotic-treated patients, 9.3% experienced adverse events, compared with 12.6% of control patients (relative risk, 0.82 [CI, 0.65 to 1.05]; I(2) = 17%).
In 13 trials, data on CDAD were missing for 5% to 45% of patients. The results were robust to worst-plausible assumptions regarding event rates in studies with missing outcome data.
Moderate-quality evidence suggests that probiotic prophylaxis results in a large reduction in CDAD without an increase in clinically important adverse events.

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    ABSTRACT: Probiotics use has increased tremendously over the past ten years. This was coupled with a surge of data relating their importance in clinical practice. Antibiotic-associated diarrhea, whose frequency has risen recently, was one of the earliest targets with data published more than ten years ago. Unfortunately, available trials suffer from severe discrepancies associated with variability and heterogeneity of several factors. Most published randomized controlled trials and subsequent meta-analyses suggest benefit for probiotics in the prevention of antibiotic-associated diarrhea. The same seems to also apply when the data is examined for Clostridium difficile-associated colitis. However, the largest randomized double-blind placebo-controlled trial to date examining the use of a certain preparation of probiotics in antibiotic- associated diarrhea showed disappointing results, but it was flawed with several drawbacks. The commonest species of probiotics studied across most trials is Lactobacillus; however, other types have also shown similar benefit. Probiotics have enjoyed an impeccable safety reputation. Despite a few reports of severe infections sometimes leading to septicemia, most of the available trials confirm their harmless behavior and show similar adverse events compared to placebo. Since a consensus dictating its use is still lacking, it would be advisable at this point to suggest prophylactic use of probiotics to certain patients at risk for antibiotic-associated diarrhea or to those who suffered previous episodes.
    World Journal of Gastroenterology 12/2014; 20(47):17788-17795. · 2.43 Impact Factor
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    BMJ quality & safety 08/2013; 22(Suppl 1):A30-A30. · 3.28 Impact Factor
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    ABSTRACT: This study investigated the clinical presentations of symptomatic Clostridium difficile infection (CDI) in children. We reviewed the medical records of 43 children aged <20 years who showed either positive C. difficile culture or C. difficile toxin test results between June 2010 and April 2014. Of the 43 patients (mean age 6.7 years), 22 were boys. Sixteen patients (37.2%) showed both positive C. difficile culture and toxin test results. Seventeen out of 43 children (39.5%) had preexisting gastrointestinal diseases, and 26 children had other medical conditions that were risk factors for CDI. Twenty-eight children had a history of antibiotic treatment for >3 days, and the most frequently prescribed antibiotic was amoxicillin-clavulanate (35.7%). Twenty-eight patients were diagnosed with CDI despite taking probiotic supplements, most commonly Lactobacillus acidophilus (53.6%). The most common symptom was diarrhea (72.1%) at the time CDI was diagnosed. C. difficile was eradicated in 11 patients (25.6%) after treatment with oral metronidazole for 10-14 days, and in the two patients (4.6%) who required two courses of oral metronidazole. Sixteen patients (37.2%) showed clinical improvement without any treatment. This study showed the various clinical characteristics of CDI in children and that preexisting clinical conditions favored the development of CDI. In addition, CDI was found to occur in a number of patients even after probiotic prophylaxis given in conjunction with antibiotic therapy.
    Pediatric gastroenterology, hepatology & nutrition. 12/2014; 17(4):232-8.


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Jun 1, 2014