Probiotics for Treatment of C. difficile in Older Patients

Search Strategy and Selection Criteria

A search of BioMed Central Journals, Cochrane Library—Cochrane Database of Systematic Reviews (Wiley), Global Health (Ovid Technologies), MEDLINE (CSA), PubMed, SCOPUS-V.4 (Elsevier) and Web of Knowledge was conducted during March 2012. Keywords included: probiotic, Clostridium difficile, AAD, intestinal microflora, immunesenescence, elderly. References were searched by hand and further relevant papers identified from their citations. The pubmed search identified 37 original papers describing the use of probiotics in AAD or CDI with seven additional papers identified manually. From these, 16 original research papers describing intervention studies were identified and included in the review.

Table 1. Clinical presentation of HBV-related membranous nephropathy
Author	n	Probiotic strain used	Study design	CDI rate probiotic (%)	CDI rate placebo (%)	Comments
Gao et al. [31]	255	Lactobacillus acidophilus CL1285® + Lactobacillus casei LBC80R®	50–70 years of age Product given for the duration of antibiotics + 5 days Follow-up: 21 days post-cessation of product	1.2^a	23.8	Probiotic blend showed positive dose-ranging effect (100 billion c.f.u. versus 50 billion); study only single-centred and only recruited patients receiving high-risk antibiotics
Sampalis et al. [33]	437	Lactobacillus acidophilus CL1285® + Lactobacillus casei LBC80R®	>18years of age Product given for the duration of antibiotics + 5 days Follow-up: 21 days post cessation of product	6.2	13.3	Multi-centre study in Canada. Patients in the active group had a shorter duration of AAD and a significantly reduced incidence (P = 0.067)
Safdar et al. [34]	40	Lactobacillus acidophilus	>18 years of age Product given for the duration of antibiotics + 14 days Follow-up: not defined	0(0/3)	25 (1/4)	This was a small pilot study and therefore underpowered. Only one CDT positive case of diarrhoea out of total of seven tested
Beausoleil et al. [36]	89	Lactobacillus acidophilus CL1285® + Lactobacillus casei	Age limits not defined; mean age in the active group 68.8 ± 14.5 Product given for the duration of antibiotics only Follow-up: 21 days post-cessation of product	2.3	15.6	Although there was a significant difference in the rate of AAD between the groups, this was not seen for CDI due to the small numbers of patients with CDI
Hickson et al. [32]	135	Lactobacillus casei DN114001, Lactobacillus Bulgaricus, Streptococcus thermophilus	≥50 years of age Product given for the duration of antibiotics + 7 days Follow-up: 4 weeks post-discharge	0	17	The NNT was six and there was a significant difference in the rate of CDI (P = 0.001) Only 8% of the screened population were recruited; therefore, it is difficult to generalise these findings to the wider hospital population
Plummer et al. [51]	138	Lactobacillus acidophilus, Bifidobacterium bifidum	Elderly patientsPrimary outcome was the rate of CDIProduct given for 20 daysFollow-up: patients were not followed up	3	7	Lower rate of CDI in the probiotic group (2.9 versus 7.25% placebo); poor recruitment to trial resulted in reduced statistical power
Surawicz et al. [52]	180	Saccharomyces boulardii	Only mean age reported in study (47.8 years ± 21) Product given for the duration of antibiotics + 2 weeks Follow-up: mean duration of 17.3 ± 8.6 days	3	5	Lower rate of CDI in the probiotic group (9.4 versus 31% placebo; P = 0.07). Intervention tested in much younger population

Table 1. Clinical presentation of HBV-related membranous nephropathy

Author

Probiotic strain used

Study design

CDI rate probiotic (%)

CDI rate placebo (%)

Comments

Gao et al. [31]

255

Lactobacillus acidophilus CL1285® + Lactobacillus casei LBC80R®

50–70 years of age
Product given for the duration of antibiotics + 5 days
Follow-up: 21 days post-cessation of product

1.2^a

23.8

Probiotic blend showed positive dose-ranging effect (100 billion c.f.u. versus 50 billion); study only single-centred and only recruited patients receiving high-risk antibiotics

Sampalis et al. [33]

437

Lactobacillus acidophilus CL1285® + Lactobacillus casei LBC80R®

>18years of age
Product given for the duration of antibiotics + 5 days
Follow-up: 21 days post cessation of product

6.2

13.3

Multi-centre study in Canada. Patients in the active group had a shorter duration of AAD and a significantly reduced incidence (P = 0.067)

Safdar et al. [34]

Lactobacillus acidophilus

>18 years of age
Product given for the duration of antibiotics + 14 days
Follow-up: not defined

0(0/3)

25 (1/4)

This was a small pilot study and therefore underpowered. Only one CDT positive case of diarrhoea out of total of seven tested

Beausoleil et al. [36]

Lactobacillus acidophilus CL1285® + Lactobacillus casei

Age limits not defined; mean age in the active group 68.8 ± 14.5 Product given for the duration of antibiotics only
Follow-up: 21 days post-cessation of product

2.3

15.6

Although there was a significant difference in the rate of AAD between the groups, this was not seen for CDI due to the small numbers of patients with CDI

Hickson et al. [32]

135

Lactobacillus casei DN114001, Lactobacillus Bulgaricus, Streptococcus thermophilus

≥50 years of age
Product given for the duration of antibiotics + 7 days
Follow-up: 4 weeks post-discharge

The NNT was six and there was a significant difference in the rate of CDI (P = 0.001) Only 8% of the screened population were recruited; therefore, it is difficult to generalise these findings to the wider hospital population

Plummer et al. [51]

138

Lactobacillus acidophilus, Bifidobacterium bifidum

Elderly patientsPrimary outcome was the rate of CDIProduct given for 20 daysFollow-up: patients were not followed up

Lower rate of CDI in the probiotic group (2.9 versus 7.25% placebo); poor recruitment to trial resulted in reduced statistical power

Surawicz et al. [52]

180

Saccharomyces boulardii

Only mean age reported in study (47.8 years ± 21)
Product given for the duration of antibiotics + 2 weeks
Follow-up: mean duration of 17.3 ± 8.6 days

Lower rate of CDI in the probiotic group (9.4 versus 31% placebo; P = 0.07). Intervention tested in much younger population