Probiotics for treating acute infectious diarrrhoea

Probiotic Drinks (Photo credit: Jepster)

Allen SJ, Martinez EG, Gregorio GV, et al. Probiotics for treating acute infectious diarrhoea. Cochrane Database Syst Rev. 2010 Nov 10;11:CD003048. (Review) PMID: 21069673PMID: 21069673

BACKGROUND: Probiotics may offer a safe intervention in acute infectious diarrhoea to reduce the duration and severity of the illness.
OBJECTIVES: To assess the effects of probiotics in proven or presumed acute infectious diarrhoea.
SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group`s trials register (July 2010), the Cochrane Controlled Trials Register (The Cochrane Library Issue 2, 2010), MEDLINE (1966 to July 2010), EMBASE (1988 to July 2010), and reference lists from studies and reviews. We also contacted organizations and individuals working in the field, and pharmaceutical companies manufacturing probiotic agents.
SELECTION CRITERIA: Randomized and quasi-randomized controlled trials comparing a specified probiotic agent with a placebo or no probiotic in people with acute diarrhoea that is proven or presumed to be caused by an infectious agent.
DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the methodological quality of the trial and extracted data. Primary outcomes were the mean duration of diarrhoea, stool frequency on day 2 after intervention and ongoing diarrhoea on day 4. A random-effects model was used.
MAIN RESULTS: Sixty-three studies met the inclusion criteria with a total of 8014 participants. Of these, 56 trials recruited infants and young children. The trials varied in the definition used for acute diarrhoea and the end of the diarrhoeal illness, as well as in the risk of bias. The trials were undertaken in a wide range of different settings and also varied greatly in organisms tested, dosage, and participants` characteristics. No adverse events were attributed to the probiotic intervention.Probiotics reduced the duration of diarrhoea, although the size of the effect varied considerably between studies.The average of the effect was significant for mean duration of diarrhoea (mean difference 24.76 hours; 95% confidence interval 15.9 to 33.6 hours; n=4555, trials=35) diarrhoea lasting >/=4 days (risk ratio 0.41; 0.32 to 0.53; n=2853, trials=29) and stool frequency on day 2 (mean difference 0.80; 0.45 to 1.14; n=2751, trials=20).The differences in effect size between studies was not explained by study quality, probiotic strain, the number of different strains, the viability of the organisms, dosage of organisms, the causes of diarrhoea, or the severity of the diarrhoea, or whether the studies were done in developed or developing countries.
AUTHORS' CONCLUSIONS: Used alongside rehydration therapy, probiotics appear to be safe and have clear beneficial effects in shortening the duration and reducing stool frequency in acute infectious diarrhoea. However, more research is needed to guide the use of particular probiotic regimens in specific patient groups

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Probioticos e Incremento de la mortalidad en pancreatitis

Probiotics are sometimes seen as innocent "alternative" medicines. They are heavily promoted as "healthy" products. This view may have to be changed, as the results from a surprising clinical trial in the Netherlands show. Cross posted with thanks from DRUGINFO. WB Probiotics have been extensively marketed for a number of ailments, including for use in diarrhoea, allergy prevention, eczema, and to accompany antibiotic use. In many cases there is insufficient scientific research or consensus for the claims being made. In many instances a strain has no efficacy similar to another being investigated. Dosages may be insufficient or gastic juices destroy the probiotic before it reaches its target. A UCT GIT specialist pointed out that in many cases the safety of many of these products have not been adequately tested and led me to this interesting article, also published in the Lancet, which concludes that in patients with predicted severe acute pancreatitis, use of this combination of probiotic strains did not reduce the risk of infections. Probiotic prophylaxis was associated with a more than two-fold increase in mortality and should therefore not be administered in this category of patients. Ned Tijdschr Geneeskd. 2008 Mar 22;152(12):685-96. Republished from: Lancet. 2008 Feb 23;371(9613):651-9. Probiotic prophylaxis in patients with predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial. [Dutch] Besselink MG, van Santvoort HC, Buskens E, Boermeester MA, van Goor H, Timmerman HM, Nieuwenhuijs VB, Bollen TL, van Ramshorst B, Witteman BJ, Rosman C, Ploeg RJ, Brink MA, Schaapherder AF, Dejong CH, Wahab PJ, van Laarhoven CJ, van der Harst E, van Eijck CH, Cuesta MA, Akkermans LM, Gooszen HG; Acute Pancreatitis Werkgroep Nederland. Collaborators (43) Afd. Heelkunde, Universitair Medisch Centrum Utrecht, Utrecht. m.besselink@umcutrecht.nl OBJECTIVE: To evaluate whether enteral prophylaxis with probiotics in patients with predicted severe acute pancreatitis prevents infectious complications. DESIGN: Multicentre, randomised, double-blind, placebo-controlled trial. 
METHOD: A total of 296 patients with predicted severe acute pancreatitis (APACHE II score > or = 8, Imrie score > or = 3 or C-reactive protein concentration > 150 mg/l) were included and randomised to one of two groups. Within 72 hours after symptom onset, patients received a multispecies preparation of probiotics or placebo given twice daily via a jejunal catheter for 28 days. The primary endpoint was the occurrence of one of the following infections during admission and go-day follow-up: infected pancreatic necrosis, bacteraemia, pneumonia,urosepsis or infected ascites. Secondary endpoints were mortality and adverse reactions. The study registration number is ISRCTN38327949. RESULTS: Treatment groups were similar at baseline with regard to patient characteristics and disease severity. Infections occurred in 30% of patients in the probiotics group (46 of 152 patients) and 28% of those in the placebo group (41 of 144 patients; relative risk (RR): 1.1; 95% CI: 0.8-1.5). The mortality rate was 16% in the probiotics group (24 of 152 patients) and 6% (9 of 144 patients) in the placebo group (RR: 2.5; 95% CI: 1.2-5.3). In the probiotics group, 9 patients developed bowel ischaemia (of whom 8 patients died), compared with none in the placebo group (p = 0.004). CONCLUSION: In patients with predicted severe acute pancreatitis, use of this combination of probiotic strains did not reduce the risk of infections. Probiotic prophylaxis was associated with a more than two-fold increase in mortality and should therefore not be administered in this category of patients.

Probioticos e Incremento de la mortalidad en pancreatitis

Probiotics are sometimes seen as innocent "alternative" medicines. They are heavily promoted as "healthy" products. This view may have to be changed, as the results from a surprising clinical trial in the Netherlands show. Cross posted with thanks from DRUGINFO. WB Probiotics have been extensively marketed for a number of ailments, including for use in diarrhoea, allergy prevention, eczema, and to accompany antibiotic use. In many cases there is insufficient scientific research or consensus for the claims being made. In many instances a strain has no efficacy similar to another being investigated. Dosages may be insufficient or gastic juices destroy the probiotic before it reaches its target. A UCT GIT specialist pointed out that in many cases the safety of many of these products have not been adequately tested and led me to this interesting article, also published in the Lancet, which concludes that in patients with predicted severe acute pancreatitis, use of this combination of probiotic strains did not reduce the risk of infections. Probiotic prophylaxis was associated with a more than two-fold increase in mortality and should therefore not be administered in this category of patients. Ned Tijdschr Geneeskd. 2008 Mar 22;152(12):685-96. Republished from: Lancet. 2008 Feb 23;371(9613):651-9. Probiotic prophylaxis in patients with predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial. [Dutch] Besselink MG, van Santvoort HC, Buskens E, Boermeester MA, van Goor H, Timmerman HM, Nieuwenhuijs VB, Bollen TL, van Ramshorst B, Witteman BJ, Rosman C, Ploeg RJ, Brink MA, Schaapherder AF, Dejong CH, Wahab PJ, van Laarhoven CJ, van der Harst E, van Eijck CH, Cuesta MA, Akkermans LM, Gooszen HG; Acute Pancreatitis Werkgroep Nederland. Collaborators (43) Afd. Heelkunde, Universitair Medisch Centrum Utrecht, Utrecht. m.besselink@umcutrecht.nl OBJECTIVE: To evaluate whether enteral prophylaxis with probiotics in patients with predicted severe acute pancreatitis prevents infectious complications. DESIGN: Multicentre, randomised, double-blind, placebo-controlled trial. 
METHOD: A total of 296 patients with predicted severe acute pancreatitis (APACHE II score > or = 8, Imrie score > or = 3 or C-reactive protein concentration > 150 mg/l) were included and randomised to one of two groups. Within 72 hours after symptom onset, patients received a multispecies preparation of probiotics or placebo given twice daily via a jejunal catheter for 28 days. The primary endpoint was the occurrence of one of the following infections during admission and go-day follow-up: infected pancreatic necrosis, bacteraemia, pneumonia,urosepsis or infected ascites. Secondary endpoints were mortality and adverse reactions. The study registration number is ISRCTN38327949. RESULTS: Treatment groups were similar at baseline with regard to patient characteristics and disease severity. Infections occurred in 30% of patients in the probiotics group (46 of 152 patients) and 28% of those in the placebo group (41 of 144 patients; relative risk (RR): 1.1; 95% CI: 0.8-1.5). The mortality rate was 16% in the probiotics group (24 of 152 patients) and 6% (9 of 144 patients) in the placebo group (RR: 2.5; 95% CI: 1.2-5.3). In the probiotics group, 9 patients developed bowel ischaemia (of whom 8 patients died), compared with none in the placebo group (p = 0.004). CONCLUSION: In patients with predicted severe acute pancreatitis, use of this combination of probiotic strains did not reduce the risk of infections. Probiotic prophylaxis was associated with a more than two-fold increase in mortality and should therefore not be administered in this category of patients.

Probiotics helpful for antibiotic-associated diarrhea

Clinical Question:

Can probiotics prevent antibiotic-associated diarrhea and assist in the treatment of Clostridium difficile disease?

Bottom Line:

The probiotics Saccharomyces boulardii and Lactobacillus rhamnosus GG both prevent antibiotic-associated diarrhea (AAD), as does a combination of 2 or more probiotics. S. boulardii, given in addition to vancomycin or metronidazole, is also an effective treatment for Clostridium difficile disease (CDD). (LOE = 1a-)

Reference:

McFarland LV. Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and the treatment of Clostridium difficile disease. Am J Gastroenterol 2006;101:812-822.

Study Design:

Meta-analysis (randomized controlled trials)

Funding:

Unknown/not stated

Setting:

Various (meta-analysis)

Synopsis:

A variety of probiotics have been proposed to help reestablish the gut flora, prevent AAD, and treat CDD. This meta-analysis identified any blinded randomized controlled trials (RCTs) on MEDLINE and Google Scholar and evaluated their quality. There were 25 RCTs of AAD prevention including 2810 patients and 6 RCTs of CDD treatment including 354 patients. Studies were generally of good quality. There was considerable heterogeneity regarding population and results for studies of prevention of AAD. Although there was no difference in outcomes for studies in adults or children or by duration of therapy, a greater benefit was seen for studies using a higher dose. S. boulardii and L. rhamnosus GG, both studied in 6 RCTs, were most effective (combined relative risk = 0.37 and 0.31, respectively) as were studies using a mixture of 2 probiotics. In most studies of the treatment of CDD, patients were also given vancomycin or metronidazole and the outcome was the likelihood of recurrence of CDD. Results of the 6 studies were homogeneous and a combined estimate of effect showed a relative risk of recurrent CDD of 0.59 (95% CI, 0.41 - 0.81). S. boulardii seemed to be the most effective probiotic. Adverse effects in both sets of studies were minimal. These studies took place largely in immunocompetent patients and should not be generalized to immunocompromised patients.

Probiotics helpful for antibiotic-associated diarrhea

Clinical Question:

Can probiotics prevent antibiotic-associated diarrhea and assist in the treatment of Clostridium difficile disease?

Bottom Line:

The probiotics Saccharomyces boulardii and Lactobacillus rhamnosus GG both prevent antibiotic-associated diarrhea (AAD), as does a combination of 2 or more probiotics. S. boulardii, given in addition to vancomycin or metronidazole, is also an effective treatment for Clostridium difficile disease (CDD). (LOE = 1a-)

Reference:

McFarland LV. Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and the treatment of Clostridium difficile disease. Am J Gastroenterol 2006;101:812-822.

Study Design:

Meta-analysis (randomized controlled trials)

Funding:

Unknown/not stated

Setting:

Various (meta-analysis)

Synopsis:

A variety of probiotics have been proposed to help reestablish the gut flora, prevent AAD, and treat CDD. This meta-analysis identified any blinded randomized controlled trials (RCTs) on MEDLINE and Google Scholar and evaluated their quality. There were 25 RCTs of AAD prevention including 2810 patients and 6 RCTs of CDD treatment including 354 patients. Studies were generally of good quality. There was considerable heterogeneity regarding population and results for studies of prevention of AAD. Although there was no difference in outcomes for studies in adults or children or by duration of therapy, a greater benefit was seen for studies using a higher dose. S. boulardii and L. rhamnosus GG, both studied in 6 RCTs, were most effective (combined relative risk = 0.37 and 0.31, respectively) as were studies using a mixture of 2 probiotics. In most studies of the treatment of CDD, patients were also given vancomycin or metronidazole and the outcome was the likelihood of recurrence of CDD. Results of the 6 studies were homogeneous and a combined estimate of effect showed a relative risk of recurrent CDD of 0.59 (95% CI, 0.41 - 0.81). S. boulardii seemed to be the most effective probiotic. Adverse effects in both sets of studies were minimal. These studies took place largely in immunocompetent patients and should not be generalized to immunocompromised patients.