Probiotics for Treatment of C. difficile in Older Patients

Secondary Prevention

Five studies have investigated probiotic use as a secondary prophylaxis against CDI relapse, with only two showing a significant effect. The first study established that in patients who had experienced a relapse of CDI, S. boulardii in combination with standard CDI treatment prevented further disease relapse [relative risk (RR) 0.43, 95% CI: 0.2–0.97].^[41] The second study, carried out by the same group, replicated these results and demonstrated that high-dose vancomycin (2 g/day) and probiotic was the most effective combination. A lower dose of vancomycin (500 mg/day) reduced CDI recurrence (21 versus 62% placebo), but at the expense of a longer mean duration of treatment.^[42] The remaining studies are limited by small sample sizes and therefore underpowered, making it difficult to draw a meaningful conclusion.^[43–45]

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