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: 17.81). 12/2012; 157(12):878-88.
Source: PubMed


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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    • "Recent meta-analysis on CDI treatment successes (Johnston et al., 2012) in faecal transplantation in CDI therapy (Brandt, 2012; Van Nood et al., 2013) and this case series shows that even in patients at high risk, with multiple severe underlying diseases, administration of multistrain probiotics might be beneficial by shortening the diseases course as well as by preventing further relapses in patients with recurrent CDI. "
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    DESCRIPTION: Probiotics in Clostridium difficile infection: reviewing the need for a multistrain probiotic
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    • "Treatment for a second or later recurrence includes a tapered or long-term vancomycin. Due to high recurrence rates and alteration of colonic microbiota with the continued use of antimicrobial drugs, new approaches in therapy include new narrow-spectrum antibiotics, probiotics, and monoclonal antibodies [10] [11] [14] [15]. "
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    • "The probiotic strains that have been reported as clinically useful include, Lactobacillus rhamnosus GG, various other Lactobacilli and Bifidobacteria strains and the yeast Saccharomyces boulardii (Hickson, 2011). The various species of probiotics that have been clinically investigated differ from studies with single strains (e.g., Saccharomyces boulardii, Lactobacillus rhamnosus GG, Bacillus clausii, Bifidobacterium longum, Clostridium butyricum miyairir, Lactobacillus acidophilus, Enterococcus faecium SF68), to studies with mixtures of two or more species of probiotics, or to a synbiotic [probiotic(s) combined with a prebiotic constituent (e.g., inulin)] (Hickson, 2011). As an example a recent meta-analysis reported the administration of probiotics for the prevention of Clostridium Difficile Associated Diarrhea (CDAD) (Johnston et al., 2012). "
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