BMJ 2002;324:1361 ( 8 June )

Papers

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 prevention and treatment of diarrhoea associated with the use of antibiotics.
Design: Meta-analysis; outcome data (proportion of patients not getting diarrhoea) were analysed, pooled, and compared to determine odds ratios in treated and control groups.
Identification: Studies identified by searching Medline between 1966 and 2000 and the Cochrane Library.
Studies reviewed Nine randomised, double blind, placebo controlled trials of probiotics.
Results: Two of the nine studies investigated the effects of probiotics in children. Four trials used a yeast (Saccharomyces boulardii), four used lactobacilli, and one used a strain of enterococcus that produced lactic acid. Three trials used a combination of probiotic strains of bacteria. In all nine trials, the probiotics were given in combination with antibiotics and the control groups received placebo and antibiotics. The odds ratio in favour of active treatment over placebo in preventing diarrhoea associated with 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 favour of active treatment over placebo.
Conclusions: The meta-analysis suggests that probiotics can be used to prevent antibiotic associated diarrhoea and that S boulardii and lactobacilli have the potential to be used in this situation. The efficacy of probiotics in treating antibiotic associated diarrhoea remains to be proved. A further large trial in which probiotics are used as preventive agents should look at the costs of and need for routine use of these agents.

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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