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Probiotics for pediatric antibiotic-associated diarrhea: a meta-analysis of randomized placebo-controlled trials

From the Complementary and Alternative Research and Education (CARE) Program (Johnston, Vohra), Stollery Children's Hospital, Department of Pediatrics, University of Alberta, Edmonton; and the Department of Community Health Sciences, Health Sciences Centre, and the Centre for Health and Policy Studies (Supina), University of Calgary, Calgary, Alta.

Correspondence to: Dr. Sunita Vohra, Director, CARE Program, Stollery Children's Hospital, Associate Professor of Pediatrics, Department of Pediatrics, University of Alberta, Aberhart Centre #1, Rm. 8213, 11402 University Ave. NW, Edmonton AB T6G 2J3; 780 407-3798; fax 780 407-2105; svohra{at}ualberta.ca

Abstract

Background: Antibiotic treatment is known to disturb gastrointestinal microflora, which results in a range of clinical symptoms — most notably, diarrhea. This is especially important in children, for whom antibiotics are prescribed frequently. Although meta-analyses have been conducted to evaluate the ability of probiotics to prevent antibiotic-induced diarrhea in the general population, little is known about which probiotic strains and doses might be of most benefit to children. Our objective in this study was to assess the efficacy of probiotics (of any specified strain or dose) for the prevention of antibiotic-associated diarrhea in children and to assess adverse events associated with the use of probiotics when coadministered with antibiotics to children.

Methods: A comprehensive search was performed of the major electronic databases (e.g., CENTRAL, MEDLINE, EMBASE, CINAHL, AMED) from their inception to January 2005. We also contacted experts and searched registries and meeting abstracts for additional relevant articles. Randomized controlled trials that compared probiotic treatment with placebo or no treatment, involving pediatric subjects less than 19 years of age were included. Two reviewers independently applied eligibility criteria and assessed the studies for methodological quality. Data were independently extracted by 2 reviewers and analyzed via the standard Cochrane methodology.

Results: Six studies were included (total n = 707 patients). The combined results, analyzed with a per-protocol method that reported on the incidence of diarrhea during antibiotic treatment, showed significant benefit for the use of probiotics over placebo (relative risk [RR] 0.43, 95% confidence interval [CI] 0.25–0.75, I² = 70.1%). In contrast, results from intention-to-treat analysis were nonsignificant overall (RR 1.01, 95% CI 0.64–1.61). Subgroup analysis on 4 studies that provided at least 5 billion single-strain colony-forming units (CFUs) daily (range 5.5–40 x 10⁹ Lactobacillus GG, L. sporogens or Saccharomyces boulardii) showed strong evidence with narrow CIs for the preventative effects of probiotics for antibiotic-associated diarrhea (RR 0.36, 95% CI 0.25–0.53, I² = 3.5%). No serious adverse events were reported.

Interpretation: The potential protective effects of probiotics to prevent antibiotic-associated diarrhea in children do not withstand intention-to-treat analysis. Before routine use is recommended, further studies (with limited losses of subjects to follow-up) are merited. Trials should involve those probiotic strains and doses with the most promising evidence (i.e., Lactobacillus GG, L. sporogens or S. boulardii at 5–40 x 10⁹ CFUs daily).

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				G. J. Leyer, S. Li, M. E. Mubasher, C. Reifer, and A. C. Ouwehand Probiotic Effects on Cold and Influenza-Like Symptom Incidence and Duration in Children Pediatrics, August 1, 2009; 124(2): e172 - e179. [Abstract] [Full Text] [PDF]

				R. L. Koretz Probiotics, Critical Illness, and Methodologic Bias Nutr Clin Pract, February 1, 2009; 24(1): 45 - 49. [Abstract] [Full Text] [PDF]

				M. D. Cabana Antibiotic-Associated Diarrhea: A Meta-analysis of the Efficacy of Probiotics AAP Grand Rounds, November 1, 2006; 16(5): 55 - 55. [Full Text] [PDF]

				Corrections Can. Med. Assoc. J., September 26, 2006; 175(7): 777 - 777. [Full Text] [PDF]

				Probiotics may help prevent antibiotic associated diarrhoea in children BMJ, September 23, 2006; 333(7569): . [Full Text] [PDF]

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