CDAD

Probiotics to Prevent Clostridium difficile–Associated Diarrhea.

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Probiotic prophylaxis lowered the incidence of CDAD by 66%.

Antibiotic treatment disturbs the normal gastrointestinal flora and raises risk for Clostridium difficile–associated diarrhea (CDAD). To evaluate the effectiveness and safety of probiotics for preventing CDAD, researchers performed a systematic review and meta-analysis. CDAD was defined as an episode of diarrhea associated with a positive C. difficile culture or toxin assay.

Twenty randomized, controlled trials that involved 3818 adults and children were included in the analysis; 18 studies were placebo controlled. Information on antibiotic regimens was not provided. Probiotics used in the trials included Bifidobacterium, Lactobacillus, Saccharomyces, and Streptococcus species.

Probiotics lowered the incidence of CDAD by approximately 66%. The incidence of adverse events, including abdominal cramping, nausea, fever and flatulence, was higher among controls than among probiotic recipients (12.6% vs. 9.3%); no serious adverse events were attributed to probiotics. The results were similar among children and adults, with lower and higher doses of probiotics, and across the different probiotic species.

Comment: The authors believe that their meta-analysis provides moderate-quality evidence to support a clinically significant protective effect of probiotics in preventing C. difficile–associated diarrhea. As with any meta-analysis, the quality of individual studies varied; the grading methodology used in this analysis required a larger sample size for the evidence to be considered high quality. Nevertheless, given the lack of serious adverse events, we might reasonably encourage use of probiotics, particularly for susceptible patients, such as those who are receiving broad-spectrum antibiotics.

Source:Journal Watch General Medicine

Clostridium difficile-Associated Diarrhea and Proton Pump Inhibitor Therapy.

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Clostridium difficile-associated diarrhea (CDAD) is a major cause of morbidity and increasing health-care costs among hospitalized patients. Although exposure to antibiotics remains the most documented risk factor for CDAD, attention has recently been directed toward a plausible link with proton pump inhibitors (PPIs). However, the results of studies on the association between CDAD and PPIs remain controversial. We have conducted a meta-analysis to summarize the association between PPIs and CDAD among hospitalized patients.

METHODS:

 

A systematic search of published literature on studies that investigated the association between PPIs and CDAD from 1990 to 2010 was conducted on Medline and PubMed. The identified articles were reviewed for additional references. The most adjusted risk estimates were extracted by two authors and summarized using random effects meta-analysis. We also conducted a subgroup analysis by study design. Publication bias was evaluated using the Begg and Egger tests. A sensitivity analysis using the Duval and Tweedie “trim-and-fill” method has also been performed.

RESULTS:

 

Twenty-three studies including close to 300,000 patients met the inclusion criteria. There was a 65% (summary risk estimate 1.69 with a 95% confidence interval (CI) from 1.395 to 1.974; P<0.000) increase in the incidence of CDAD among patients on PPIs. By study design, whether case–control study (17) or cohort study (6), there was still a significant increase in the incidence of CDAD among PPI users. The risk estimates were 2.31 (95% CI from 1.72 to 3.10; P<0.001) and 1.48 (95% CI from 1.25 to 1.75; P<0.001) for cohort and case–control studies, respectively.

CONCLUSIONS:

 

There is sufficient evidence to suggest that PPIs increase the incidence of CDAD. Our meta-analysis shows a 65% increase in the incidence of CDAD among PPI users. We recommend that the routine use of PPIs for gastric ulcer prophylaxis should be more prudent. Establishing a guideline for the use of PPI may help in the future with the judicious use of PPIs. Further studies, preferably prospective, are needed to fully explore the association between PPIs and CDAD.

Source: American journal of gastroenterology.