Probiotics for the prevention of antibiotic-associated diarrhoea in older patients: a systematic review

Early use of probiotics might prevent antibiotic-associated diarrhea in elderly (>65 years): a systematic review and meta-analysis

Background

Antibiotic-associated diarrhea (AAD) is diarrhea associated with consuming antibiotics that cannot be explained by other causes. AAD prolongs admission time and increases mortality and financial costs. Elderly individuals are more prone to receive antibiotic treatment and develop AAD. The finding that living probiotic microorganisms decrease AAD incidence in adults (<65 years) has been clarified. However, it is controversial among elderly individuals.

Methods

We aimed to explore whether probiotics could prevent AAD in elderly individuals. We searched three electronic databases (PubMed, EMBASE, and The Cochrane Library), and two reviewers independently screened and assessed the studies. RevMan5.4 software was used to perform a meta-analysis according to the PRISMA guidelines.

Results

Eight RCTs of 4691 participants were included. We excluded two large studies because probiotics were used 48 hours after the first dose of antibiotics, and there was no effect. Subgroup analysis of 6 RCTs showed that probiotics given within two days of antibiotic treatment produced a lower AAD prevalence rate in elderly individuals.

Conclusion

We recommend that elderly individuals could be routinely distributed probiotics to prevent AAD development when receiving antibiotic treatment.

Trial registration

The review was not registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03257-3.

Probiotics for the prevention of antibiotic-associated diarrhoea: a systematic review and meta-analysis

OBJECTIVE

To evaluate existing evidence for the use of probiotics in preventing antibiotic-associated diarrhoea (AAD) in adults.

DESIGN

Systematic review and meta-analysis of randomised controlled trials (RCTs).

DATA SOURCES

We performed a literature search of the electronic databases CINAHL Plus, EMBASE, MEDLINE (Ovid) and Web of Science from database inception to May 2021 as well as hand searching of trial registries and reference lists of related reviews.

STUDY SELECTION

Two reviewers identified whether RCTs met the following inclusion criteria: adult population to whom antibiotics were administered; a probiotic intervention; a placebo, alternative dose, alternative probiotic strain or no treatment control; and incidence of AAD as the outcome.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently collected data and assessed risk of bias using preconstructed data extraction forms. We used a random effects model for all analyses. Subgroup analyses were performed to evaluate species-specific and dose-specific response.

RESULTS

Forty-two studies (11,305 participants) were included in this review. The pooled analysis suggests that co-administration of probiotics with antibiotics reduces the risk of AAD in adults by 37% (risk ratio (RR)=0.63 (95% CI 0.54 to 0.73), p<0.00001). The overall quality of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria was found to be moderate. In subgroup analyses, high dose compared with low dose of the same probiotic demonstrated a positive protective effect (RR 0.54 (95% CI 0.38 to 0.76), p<0.01), and only certain species, mainly of the lactobacillus and bifidobacteria genera, were found to be effective. Studies with a low baseline AAD risk did not show any difference in risk but studies with moderate or high baseline AAD risk demonstrated a significant risk reduction.

CONCLUSIONS

Probiotics are effective for preventing AAD. Secondary analyses of higher dosages and certain species have shown increased effectiveness. Our results may not be applicable in clinical scenarios of lower baseline AAD risk.

Clinical guidelines “Chronic diarrhea in adults”

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The Effect of Probiotics on Health Outcomes in the Elderly: A Systematic Review of Randomized, Placebo-Controlled Studies

Increasing evidence suggests that probiotic supplementation may be efficacious in counteracting age-related shifts in gut microbiota composition and diversity, thereby impacting health outcomes and promoting healthy aging. However, randomized controlled trials (RCTs) with probiotics in healthy older adults have utilized a wide variety of strains and focused on several different outcomes with conflicting results. Therefore, a systematic review was conducted to determine which outcomes have been investigated in randomized controlled trials with probiotic supplementation in healthy older adults and what has been the effect of these interventions. For inclusion, studies reporting on randomized controlled trials with probiotic and synbiotic supplements in healthy older adults (defined as minimum age of 60 years) were considered. Studies reporting clinical trials in specific patient groups or unhealthy participants were excluded. In addition to assessment of eligibility and data extraction, each study was examined for risk of bias and quality assessment was performed by two independent reviewers. Due to the heterogeneity of outcomes, strains, study design, duration, and methodology, we did not perform any meta-analyses and instead provided a narrative overview of the outcomes examined. Of 1997 potentially eligible publications, 17 studies were included in this review. The risk of bias was low, although several studies failed to adequately describe random sequence generation, allocation concealment, and blinding. The overall study quality was high; however, many studies did not include sample calculations, and the majority of studies had a small sample size. The main outcomes examined in the trials included microbiota composition, immune-related measurements, digestive health, general well-being, cognitive function, and lipid and other biomarkers. The most commonly assessed outcome with the most consistent effect was microbiota composition; all but one study with this outcome showed significant effects on gut microbiota composition in healthy older adults. Overall, probiotic supplementation had modest effects on markers of humoral immunity, immune cell population levels and activity, as well as the incidence and duration of the common cold and other infections with some conflicting results. Digestive health, general-well-being, cognitive function, and lipid and other biomarkers were investigated in a very small number of studies; therefore, the impact on these outcomes remains inconclusive. Probiotics appear to be efficacious in modifying gut microbiota composition in healthy older adults and have moderate effects on immune function. However, the effect of probiotic supplementation on other health outcomes remains inconclusive, highlighting the need for more well-designed, sufficiently-powered studies to investigate if and the mechanisms by which probiotics impact healthy aging.

Management of patients with digestive diseases during the COVID-19 pandemic. Clinical Practice Guidelines by the Russian scientific medical society of internal medicine (RSMSIM) and the Gastroenterological Scientific Society of Russia (2nd edition)

The presented clinical practice guidelines of the Gastroenterological Scientific Society of Russia (GSSR), diagnostic, and therapeutic approaches for patients with digestive diseases during the COVID-19 pandemic. The guidelines were approved by the XXIII Congress of the GSSR and the 22nd International Slavonic-Baltic Scientifi c Forum “St. Petersburg - Gastro-2020 ON-LINE” (St. Petersburg, June 11, 2020). The presented clinical practice guidelines of the Russian Scientific Medical Society of Internal Medicine (RSMSIM) and the Gastroenterological Scientific Society of Russia (GSSR), diagnostic, and therapeutic approaches for patients with digestive diseases during the COVID-19 pandemic. The recommendations were approved at the XV National Congress of Internal Medicine, XXIII Congress of NOGR on the basis of the 1st edition, adopted at the 22nd International Slavic- Baltic Scientific Forum “St. Petersburg - Gastro-2020 ON-LINE”.

Effect of probiotics on diversity and function of gut microbiota in Moschus berezovskii

The forest musk deer, Moschus berezovskii, is a nationally protected species of economic importance in China. However, in captive breeding programmes, they usually die as a result of diarrhoea. In this study, six M. berezovskii were randomly selected and divided into two groups: probiotics group (n = 3) and placebo (control) group (n = 3). The two groups were fed a basal diet that included 2 g probiotics (probiotic group) or 2 g whey powder (placebo group) for 30 days. Faecal samples were collected at day 0, 15 and 30 and evaluated for microbial diversity, species richness and metabolic function. Probiotic intervention significantly improved gut health in M. berezovskii by changing the overall community structure of the gut microbiota. Intake of probiotics reduced the relative abundance of pathogenic bacteria such as Escherichia coli and Citrobacter freundii in the intestinal flora and increased the relative abundance of beneficial Bifidobacterium species and other lactic acid bacteria. At the same time, gut microbiota in the probiotics group were involved in regulating degradation of phenylacetic acid and in dTDP-L-rhamnose synthesis; these processes have the potential to enhance immunity in M. berezovskii. This preliminary study revealed the beneficial effects of probiotics on the gut microbiota of M. berezovskii, which the potential to significantly improve the health, wellbeing and economic value of M. berezovskii.

Physiological Characteristics of Lactobacillus casei Strains and Their Alleviation Effects against Inflammatory Bowel Disease

Lactobacillus casei, one of the most widely used probiotics, has been reported to alleviate multiple diseases. However, the effects of this species on intestinal diseases are strain-specific. Here, we aimed to screen L. casei strains with inflammatory bowel disease (IBD)-alleviating effects based on in vitro physiological characteristics. Therefore, the physiological characteristics of 29 L. casei strains were determined, including gastrointestinal transit tolerance, oligosaccharide fermentation, HT-29 cell adhesion, generation time, exopolysaccharide production, acetic acid production, and conjugated linoleic acid synthesis. The effects of five candidate strains on mice with induced colitis were also evaluated. The results showed that among all tested L. casei strains, only Lactobacillus casei M2S01 effectively relieved colitis. This strain recovered body weight, restored disease activity index score, and promoted anti-inflammatory cytokine expression. Gut microbiota sequencing showed that L. casei M2S01 restored a healthy gut microbiome composition. The western blotting showed that the alleviating effects of L. casei M2S01 on IBD were related to the inhibition of the NF-κB pathway. A good gastrointestinal tolerance ability may be one of the prerequisites for the IBDalleviating effects of L. casei. Our results verified the efficacy of L. casei in alleviating IBD and lay the foundation for the rapid screening of L. casei strain with IBD-alleviating effects.

Prevention of Clostridium difficile Infection and Associated Diarrhea: An Unsolved Problem

For many years, it has been known that Clostridium difficile (CD) is the primary cause of health-care-associated infectious diarrhea, afflicting approximately 1% of hospitalized patients. CD may be simply carried or lead to a mild disease, but in a relevant number of patients, it can cause a very severe, potentially fatal, disease. In this narrative review, the present possibilities of CD infection (CDI) prevention will be discussed. Interventions usually recommended for infection control and prevention can be effective in reducing CDI incidence. However, in order to overcome limitations of these measures and reduce the risk of new CDI episodes, novel strategies have been developed. As most of the cases of CDI follow antibiotic use, attempts to rationalize antibiotic prescriptions have been implemented. Moreover, to reconstitute normal gut microbiota composition and suppress CD colonization in patients given antimicrobial drugs, administration of probiotics has been suggested. Finally, active and passive immunization has been studied. Vaccines containing inactivated CD toxins or components of CD spores have been studied. Passive immunization with monoclonal antibodies against CD toxins or the administration of hyperimmune whey derived from colostrum or breast milk from immunized cows has been tried. However, most advanced methods have significant limitations as they cannot prevent colonization and development of primary CDI. Only the availability of vaccines able to face these problems can allow a resolutive approach to the total burden due to this pathogen.

Risk factors, incidence, and morbidity associated with antibiotic-associated diarrhea in intensive care unit patients receiving antibiotic monotherapy

BACKGROUND

This study aimed to identify factors associated with antibiotic-associated diarrhea (AAD) in patients in the department of intensive care medicine who received antibiotic monotherapy in order to reduce the incidence of AAD and improve rational use of antibiotics in these patients.

AIM

To report the incidence of AAD and the factors associated with AAD in patients receiving antibiotic monotherapy.

METHODS

The study used a single-center retrospective design. A total of 209 patients were enrolled. Patients were divided into two groups: No-AAD group (without AAD) and AAD group (with AAD). There were 45 cases in the AAD group and 164 cases in the no-AAD group. Clinical data of all patients were collected. Data were analyzed using SPSS (version 18.0), and statistical significance was set at P < 0.05.

RESULTS

The overall incidence of AAD was 21.53%. Age [odds ratio (OR) 1.022, 95% confidence interval (CI): 1.001-1.044, P = 0.040], proton pump inhibitor usage time (OR 1.129, 95%CI: 1.020-1.249, P = 0.019), antibiotic usage time (OR 1.163, 95%CI: 1.024-1.320, P = 0.020), and intensive care unit (ICU) stay time (OR 1.133, 95%CI: 1.041-1.234, P = 0.004) were associated with AAD in ICU patients receiving antibiotic monotherapy. mean ± SD ICU stay time was lower in the no-AAD group (8.49 ± 6.31 vs 15.89 ± 10.69, P < 0.001). However, there was no significant difference in ICU-related mortality rates between the two groups (P = 0.729).

CONCLUSION

Older age, longer ICU stay time, duration of use of proton pump inhibitors, and duration of antibiotic increase the incidence of AAD in ICU patients receiving antibiotic monotherapy.

Lactobacillus sp as a Probiotic for the Prevention of Clostridium difficile Associated Diarrhea

Background: Antibiotic treatment can disturb the resistance of the gastrointestinal flora to colonization. This may result in complications, the most serious of which is Clostridium difficile associated diarrhea (CDAD). The aim of this study was to determine the effectiveness of probiotics for the prevention of CDAD.Method: The databases used were Scopus, Proquest, CINAHL, Medline, Pubmed and ScienceDirect, limited to having been published in the last 5 years. A literature review followed the keyword search. The keywords used were probiotics, Clostridium difficile, associated, diarrhea, randomized, control and trial using "AND" and “OR”. Twelve trials with 5102 participants were included. Eight trials reported a preventive effect for CDAD using a mixture of 2 strains of lactobacillus, a mixture of 4 combination strains, a mixture of lactobacillus and Saccharomyces or a mixture of Bifidobacterium, Lactobacillus and Saccharomyces.Result: Our findings indicate that probiotics may prevent CDAD. Most probiotics contain a singular strain. The combination with lactobacillus sp was the most effective at preventing CDAD.Conclusion: In addition, 6 out of 8 trials had an in relation to preventing CDAD containing lactobacillus sp. Four studies said that there were some factors that meant that the probiotic could not reduce or prevent the CDAD.

Probiotics, prebiotics and amelioration of diseases

Dysbiosis of gut microbiota is closely related to occurrence of many important chronic inflammations-related diseases. So far the traditionally prescribed prebiotics and probiotics do not show significant impact on amelioration of these diseases in general. Thus the development of next generation prebiotics and probiotics designed to target specific diseases is urgently needed. In this review, we first make a brief introduction on current understandings of normal gut microbiota, microbiome, and their roles in homeostasis of mucosal immunity and gut integrity. Then, under the situation of microbiota dysbiosis, development of chronic inflammations in the intestine occurs, leading to leaky gut situation and systematic chronic inflammation in the host. These subsequently resulted in development of many important diseases such as obesity, type 2 diabetes mellitus, liver inflammations, and other diseases such as colorectal cancer (CRC), obesity-induced chronic kidney disease (CKD), the compromised lung immunity, and some on brain/neuro disorders. The strategy used to optimally implant the effective prebiotics, probiotics and the derived postbiotics for amelioration of the diseases is presented. While the effectiveness of these agents seems promising, additional studies are needed to establish recommendations for most clinical settings.

Probiotics in Gastroenterology: How Pro Is the Evidence in Adults?

Probiotic usage has become popular with both medical practitioners and the community in general; patients commonly seek advice regarding what, if any, such preparation would be useful for their own diseases. Since such advice should be evidence-based, identified randomized clinical trials (RCTs) for a number of gastrointestinal conditions were reviewed; the data were organized by individual probiotic genera/species. Only trials in adults were considered. Most of the identified RCTs were small and low-quality, so any conclusions to be drawn will be limited at least by methodologic problems. Using the GRADE system to consider the reliability of the evidence generated from these RCTs, it did appear that the use of fecal microbial transplantation to treat recurrent Clostridium difficile infection is well justified. Given the methodologic issues, there was moderately good evidence for preventing antibiotic-associated diarrhea with Lactobacillus, Bifidobacterium, Streptococcus, or Saccharomyces boulardii and for using Lactobacillus, Bifidobacterium, or Saccharomyces as adjunct therapy in the treatment of Helicobacter pylori. There were other conditions for which some supportive evidence was available. These conditions include VSL#3 for maintaining remissions in patients with pouchitis or treating active ulcerative colitis (UC), fecal microbial transplantation for treating active UC, Bifidobacterium for treating patients with UC in remission, Lactobacillus in patients with painful diverticulosis, a variety of probiotics (Lactobacillus, Bifidobacterium, Streptococcus, or VSL#3) in patients with minimal hepatic encephalopathy, and providing synbiotics to patients postoperatively after liver transplantation. Unfortunately, other limitations in the evidence made it very likely that future research will have an effect on the estimated benefit; these interventions cannot yet be recommended for routine use.

Acid-Suppressive Therapy and Risk of Infections: Pros and Cons

This narrative review summarises the benefits, risks and appropriate use of acid-suppressing drugs (ASDs), proton pump inhibitors and histamine-2 receptor antagonists, advocating a rationale balanced and individualised approach aimed to minimise any serious adverse consequences. It focuses on current controversies on the potential of ASDs to contribute to infections-bacterial, parasitic, fungal, protozoan and viral, particularly in the elderly, comprehensively and critically discusses the growing body of observational literature linking ASD use to a variety of enteric, respiratory, skin and systemic infectious diseases and complications (Clostridium difficile diarrhoea, pneumonia, spontaneous bacterial peritonitis, septicaemia and other). The proposed pathogenic mechanisms of ASD-associated infections (related and unrelated to the inhibition of gastric acid secretion, alterations of the gut microbiome and immunity), and drug-drug interactions are also described. Both probiotics use and correcting vitamin D status may have a significant protective effect decreasing the incidence of ASD-associated infections, especially in the elderly. Despite the limitations of the existing data, the importance of individualised therapy and caution in long-term ASD use considering the balance of benefits and potential harms, factors that may predispose to and actions that may prevent/attenuate adverse effects is evident. A six-step practical algorithm for ASD therapy based on the best available evidence is presented.

The role of the microbiome and the use of probiotics in gastrointestinal disorders in adults in the Asia-Pacific region - background and recommendations of a regional consensus meeting

The Asia-Pacific region is diverse, with regard to ethnicity, culture, and economic development incorporating some of the world's least and most developed nations. Gastrointestinal diseases are common in the Asia-Pacific region, and their prevalence, presentation, and management vary considerably within the region. There is growing evidence for an important role for the human gut microbiota in gastrointestinal health. As a consequence, geographic variations in the composition of the gut microbiota may contribute to variations in both the prevalence and response to therapy of specific diseases. Probiotics have been proposed as a valuable option in the prevention and treatment of a number of gastrointestinal illnesses, but the quality of available evidence to support their efficacy is variable. A meeting of international experts in adult and pediatric gastroenterology was held at the Sorbonne University, Paris, France, on April 11 and 12, 2016, to discuss current evidence supporting the use of probiotics in gastrointestinal disorders in the Asia-Pacific region. This article provides an overview of the discussions held at this meeting and recommends the formation of an Asia-Pacific Consortium on Gut Microbiota similar to those established in Europe and North America.

Proteomic analysis of stachyose contribution to the growth of Lactobacillus acidophilus CICC22162

Stachyose is a functional oligosaccharide, acting as a potential prebiotic for colonic fermentation.

Evidence-Based Practice in the Treatment for Antibiotic-Associated Diarrhea in the Intensive Care Unit

Unit nurses provide care to patients with serious health conditions. Often antibiotics are recommended to fight infections. Sometimes patients are on proton pump inhibitors (PPI). Antibiotics and PPIs may lead to diarrhea, causing the patient more discomfort, and possibly leading to a more serious infection. One serious infection is caused by Clostridium difficile, which causes death in some cases. About 75% of patients on antibiotics may not need antibiotics. Several studies showed less diarrhea in patients on probiotics. However, probiotics cause harm to some patients, which needs to be considered. Nurses need to ensure that antibiotic stewardship is followed.

Saccharomyces cerevisiae var. boulardii fungemia following probiotic treatment

Probiotics are commonly prescribed as an adjuvant in the treatment of antibiotic-associated diarrhea caused by Clostridium difficile. We report the case of an immunocompromised 73-year-old patient on chemotherapy who developed Saccharomyces cerevisiae var. boulardii fungemia in a central venous catheter during treatment of antibiotic-associated pseudomembranous colitis with the probiotic Saccharomyces cerevisiae var. boulardii. Fungemia was resolved after interruption of probiotic administration without the need to replace the central venous line.

Comparison of pediatric and adult antibiotic-associated diarrhea and Clostridium difficile infections

Antibiotic-associated diarrhea (AAD) and Clostridum difficile infections (CDI) have been well studied for adult cases, but not as well in the pediatric population. Whether the disease process or response to treatments differs between pediatric and adult patients is an important clinical concern when following global guidelines based largely on adult patients. A systematic review of the literature using databases PubMed (June 3, 1978-2015) was conducted to compare AAD and CDI in pediatric and adult populations and determine significant differences and similarities that might impact clinical decisions. In general, pediatric AAD and CDI have a more rapid onset of symptoms, a shorter duration of disease and fewer CDI complications (required surgeries and extended hospitalizations) than in adults. Children experience more community-associated CDI and are associated with smaller outbreaks than adult cases of CDI. The ribotype NAP1/027/BI is more common in adults than children. Children and adults share some similar risk factors, but adults have more complex risk factor profiles associated with more co-morbidities, types of disruptive factors and a wider range of exposures to C. difficile in the healthcare environment. The treatment of pediatric and adult AAD is similar (discontinuing or switching the inciting antibiotic), but other treatment strategies for AAD have not been established. Pediatric CDI responds better to metronidazole, while adult CDI responds better to vancomycin. Recurrent CDI is not commonly reported for children. Prevention for both pediatric and adult AAD and CDI relies upon integrated infection control programs, antibiotic stewardship and may include the use of adjunctive probiotics. Clinical presentation of pediatric AAD and CDI are different than adult AAD and CDI symptoms. These differences should be taken into account when rating severity of disease and prescribing antibiotics.

[Enteric microbiocenotic modifiers and ways of enhancing their efficacy]

Efficient recovery of enteric microbiocenosis is one of the central problems not only in gastroenterology, but also in a number of related areas. This problem becomes particularly pressing after antibiotic treatment. The combined modifiers of enteric microbiocenosis are most effective among other symbiotic drugs. Bion-3 apart from symbionts contains a vitamin/mineral complex and acts as an adaptogen.

Systematic review with meta-analysis: Lactobacillus rhamnosus GG in the prevention of antibiotic-associated diarrhoea in children and adults

BACKGROUND

The effects of probiotics are strain specific. The clinical effects of each strain need to be evaluated separately.

AIM

To evaluate the efficacy of Lactobacillus rhamnosus GG (LGG) in the prevention of antibiotic-associated diarrhoea (AAD) in children and adults.

METHODS

The Cochrane Library, MEDLINE, and EMBASE databases were searched up to July 2015, with no language restrictions, for randomised controlled trials (RCTs). Reference lists of reviews and included studies were examined. The quality of evidence (QoE) was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines.

RESULTS

Twelve RCTs (1499 participants) were included. Treatment with LGG compared with placebo or no additional treatment reduced the risk of AAD in patients treated with antibiotics from 22.4% to 12.3% (11 RCTs, n = 1308, relative risk, RR: 0.49, 95% confidence interval, CI: 0.29-0.83, low QoE). However, when children and adults were evaluated separately, the difference was significant in children only (five RCTs, n = 445, RR 0.48, 95% CI 0.26-0.89; moderate QoE). In adults, the difference was not significant (six RCTs, n = 863, RR 0.48, 95% CI 0.20-1.15; low QoE), except for in a subset of patients receiving antibiotics as part of Helicobacter pylori eradication therapy (four RCTs, n = 280, RR 0.26, 95% CI 0.11-0.59; low QoE).

CONCLUSIONS

This meta-analysis shows that Lactobacillus rhamnosus GG is effective in preventing antibiotic-associated diarrhoea in children and adults treated with antibiotics for any reason. However, the quality of evidence is moderate to low.