Probiotics a Must with Antibiotics

March 22 2013

by alex

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There has been high quality evidence showing that probiotics reduce the risk of antibiotic-associated diarrhea for years, yet very few physicians actually recommend the addition of a probiotic when an antibiotic is prescribed. The strength of the evidence is Grade “A”, the highest level.

This is a perfect example of physicians either not keeping up with the literature or simply ignoring the evidence.

Last year the Journal of the American Medical Association, a very mainstream medical publication, published a meta-analysis on this topic. Has this impacted physician behavior? Does your physician recoomend probiotics when antibiotics are prescribed?

This month, March 2013, the Journal of Family Practice published a PURL, a Priority Update from the Research Literature on this topic, referencing the JAMA meta-analysis. Will this encourage a change in the behavior of Family Physicians?

Probiotics for the Prevention and Treatment of Antibiotic-Associated DiarrheaA Systematic Review and Meta-analysis

Susanne Hempel, Sydne J. Newberry, Alicia R. Maher, Zhen Wang, Jeremy N. V. Miles, Roberta Shanman, Breanne Johnsen, Paul G. Shekelle
JAMA. 2012;307(18):1959-1969. doi:10.1001/jama.2012.3507

Context: Probiotics are live microorganisms intended to confer a health benefit when consumed. One condition for which probiotics have been advocated is the diarrhea that is a common adverse effect of antibiotic use.

Objective: To evaluate the evidence for probiotic use in the prevention and treatment of antibiotic-associated diarrhea (AAD).

Data Sources: Twelve electronic databases were searched (DARE, Cochrane Library of Systematic Reviews, CENTRAL, PubMed, EMBASE, CINAHL, AMED, MANTIS, TOXLINE, ToxFILE, NTIS, and AGRICOLA) and references of included studies and reviews were screened from database inception to February 2012, without language restriction.

Study Selection: Two independent reviewers identified parallel randomized controlled trials (RCTs) of probiotics (Lactobacillus, Bifidobacterium, Saccharomyces, Streptococcus, Enterococcus, and/or Bacillus) for the prevention or treatment of AAD.

Data Extraction: Two independent reviewers extracted the data and assessed trial quality.

Results: A total of 82 RCTs met inclusion criteria. The majority used Lactobacillus -based interventions alone or in combination with other genera; strains were poorly documented. The pooled relative risk in a DerSimonian-Laird random-effects meta-analysis of 63 RCTs, which included 11 811 participants, indicated a statistically significant association of probiotic administration with reduction in AAD (relative risk, 0.58; 95% CI, 0.50 to 0.68; P < .001; I2, 54%; [risk difference, −0.07; 95% CI, −0.10 to −0.05], [number needed to treat, 13; 95% CI, 10.3 to 19.1]) in trials reporting on the number of patients with AAD. This result was relatively insensitive to numerous subgroup analyses. However, there exists significant heterogeneity in pooled results and the evidence is insufficient to determine whether this association varies systematically by population, antibiotic characteristic, or probiotic preparation.

Conclusions: The pooled evidence suggests that probiotics are associated with a reduction in AAD. More research is needed to determine which probiotics are associated with the greatest efficacy and for which patients receiving which specific antibiotics.

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