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Trial Review Finds Probiotic Benefit For Antibiotic Diarrhoea

Probiotics can help prevent antibiotic-associated diarrhoea, finds a meta-analysis of nine randomised, double blind, placebo controlled trials.

"Data from trials have provided us with clear evidence on the efficacy of some strains in the gut, but we still need to see confirmation of their clinical benefit," declare clinicians at the Faculty of Medicine, Imperial College School of Medicine, Hammersmith Hospital, London, England.

The study, headed by Dr Christopher Bulpitt, Professor of Geriatric Medicine, included two of the nine trials which 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.

Researchers note that the term "probiotic" was first used to describe "a live microbial supplement, which beneficially affects the host by improving its microbial balance." Since the mid 1990s, with a greater understanding of their properties, the term "biotherapeutic agents" has been proposed for microorganisms with specific therapeutic properties that also inhibit the growth of pathogenic bacteria.

The first to be isolated and studied with a view to clinical use included Streptococcus thermophilus and Lactobacillus bulgaricus, which are commonly used in the dairy industry. Other strains being used include Bifidobacterium bifidum, B longum, Enterococcus faecium, Saccharomyces boulardii, L acidophilus, L casei, and Lactobacillus GG.

"However, doctors are still reluctant to use these agents in clinical practice," Dr Bulpitt points out. In all nine trials which the clinicians reviewed, the probiotics were given in combination with antibiotics and the control groups received placebo and antibiotics.

They found that probiotics are useful in preventing antibiotic-associated diarrhoea with the odds ratio in favor of active treatment over placebo in preventing diarrhea associated with antibiotics was 0.39 for the yeast and 0.34 for lactobacilli.

The combined odds ratio was 0.37 in favor of active treatment over placebo. In particular, S boulardii and three strains of Lactobacillus have the potential to be used in this situation.

Commercially available strains are being marketed in capsules and yogurt based drinks, but these were not tested in the trials and their potential benefit needs further investigation, the clinicians said.

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.

Dr Bulpitt and colleagues conclude that - in light of the need to control costs - "we must reexamine the benefits of using live organisms.

Whether the use of probiotics can actually reduce the length of hospital stay by reducing the incidence of infection with C difficile and the need to use antibiotics such as metronidazole and vancomycin are issues that need to be addressed in a clinical trial."
BMJ 2002;324:1361-4.

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