Probiotics in prevention of antibiotic associated diarrhoea: meta-analysis

doi:10.1136/bmj.324.7350.1361

BMJ 2002;324:1361 ( 8 June )

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Probiotics in prevention of antibiotic associated diarrhoea: meta-analysis

Aloysius L D'Souza, research fellow, Chakravarthi Rajkumar, senior lecturer and honorary consultant, Jonathan Cooke, statistician, Christopher J Bulpitt, professor of geriatric medicine.

Care of the Elderly Section, Faculty of Medicine, Imperial College School of Medicine, Hammersmith Hospital, London W12 0NN

Correspondence to: A L D'Souza aloysius.dsouza{at}ic.ac.uk

Objective: To evaluate efficacy of probiotics in preventionand treatment of diarrhoea associated with the use ofantibiotics.
Design: Meta-analysis; outcome data (proportion ofpatients not getting diarrhoea) were analysed, pooled, and comparedto determine odds ratios in treated and controlgroups.
Identification: Studies identified by searching Medline between1966 and 2000 and the CochraneLibrary.
Studies reviewed Nine randomised, double blind, placebo controlled trials ofprobiotics.
Results: Two of the nine studies investigated the effectsof probiotics in children. Four trials used a yeast (Saccharomycesboulardii), four used lactobacilli, and one used a strain of enterococcusthat produced lactic acid. Three trials used a combination ofprobiotic strains of bacteria. In all nine trials, the probioticswere given in combination with antibiotics and the control groupsreceived placebo and antibiotics. The odds ratio in favour ofactive treatment over placebo in preventing diarrhoea associatedwith antibiotics was 0.39 (95% confidence interval 0.25 to 0.62;P<0.001) for the yeast and 0.34 (0.19 to 0.61; P<0.01 for lactobacilli.The combined odds ratio was 0.37 (0.26 to 0.53; P<0.001) in favourof active treatment overplacebo.
Conclusions: The meta-analysis suggests that probioticscan be used to prevent antibiotic associated diarrhoea and thatS boulardii and lactobacilli have the potential to be used inthis situation. The efficacy of probiotics in treating antibioticassociated diarrhoea remains to be proved. A further large trialin which probiotics are used as preventive agents should lookat the costs of and need for routine use of theseagents.

What is already known on this topic
Probiotics are well known for their microbiological properties and have been used to treat gastrointestinal and vaginal mucosal infections

Conflicting results have prevented probiotics from being accepted as viable alternatives to conventional treatments for antibiotic associated diarrhoea

The commercial availability of probiotics is increasing

What this study adds
Probiotics may prevent antibiotic associated diarrhoea

The potential of specific probiotics to prevent Clostridium difficile infection secondary to the use of antibiotics should be re-examined

A large trial looking at the efficacy of probiotics in preventing antibiotic associated diarrhoea, particularly in elderly patients, with an emphasis on the optimal dose and cost benefits is needed

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