In the contemporary medical world, questions over the efficacy of the use of the probiotics in the prevention of Clostridium difficle-mediated diarrhea, which is a side effect of antibiotic utilization, linger in the minds of many scientists. That is the case given there is no consensus on whether such an inclusion in the treatment plan of patients on antibiotics will result in an effect of this kind or not. Such a state of affairs necessitates a quick fix that will bring in harmony to the already in use health care sector’s guidelines of infection management. As such, this paper aims to seek clarity on this matter by a review of the literature to establish the current state of the evidence.
Dietrich, Kottmann, and Alavi, (2014) are of the opinion that 5-49% of patients on antibiotics suffer from diarrhea. More specifically, 10-25% of the diarrhea cases are due to the Clostridium difficile, which poses a severely life-threatening condition. Such a statistic of the antibiotic-associated diarrhea is disheartening. Moreover, it has necessitated a rethink of the management strategy adopted in the clinical management of infections. The ramification of this kind of evaluation process is the development of new strategies. A case in point of such newly adopted measures is the use probiotics in preventing diarrhea. Information about its efficacy as a preventive measure for antibiotic-associated diarrhea abounds, but discrepancies are manifest across the findings of those studies. That notwithstanding, a paucity of studies that look into the specific doses and strains, which are effective for a particular population exists. As such, there is a need for such research that will focus on meeting this goal.
History of Probiotics and Antibiotics use in Clinical Practice.According to Angelakis, Merhej, and Raoult, (2013), the use of probiotics and antibiotics in clinical practice owes its origin to its efficacy in improving agricultural outcomes. Additionally, the first reports of probiotics date back more than 100 years ago (Issa, & Moucari, 2014). Over the years, the reliance on the probiotics and antibiotics has grown significantly because their concurrent usage has shown to yield good health care outcomes.
Definitionrelated to probiotic use. The literature has used various terms associated with this topic worse meanings are worth noting. They include the following:
Probiotics.They are commonly located in dietary supplements or yogurts and constitute possibly beneficial bacteria or yeast, which help in the maintenance of equilibrium the bacteria in the intestinal lumen (Goldenberg, Lytvyn, Steurich, Parkin, Mahant, & Johnston, 2015).
Antibiotic-associated diarrhea.It refers to the type diarrhea that occurs soon after the disturbance of the normal flora equilibrium causing pathogenic bacteria to multiply significantly in the intestinal tract (Issa, & Moucari, 2014).
Clostridium difficle.A spore-forming rod Gram-positive bacterium whose first description was in 1935 after its contribution to the development of newborn infections (Issa, & Moucari, 2014).
Current Management Protocols of Antibiotic-associated Diarrhea. Individuals suffering from the antibiotic-associated form of diarrhea are subject to isolation until stool cultures have proven beyond reasonable doubt that this case of diarrhea is not Clostridium difficile-mediated diarrhea (Dietrich, Kottmann, & Alavi, 2014). Such a management strategy lowers the quality of care that the isolated patients receive, which is unacceptable. It is more common in hospitals that lack a microbiology department within its premises. However, this should not be the case in this era of nosocomial infections like Clostridium difficile-mediated diarrhea, which have a high potential of killing many people(Dietrich, Kottmann, & Alavi, 2014).
Significance of the Topic
As reported by Centers for Disease Control and Prevention, (2013), in the USA, the prevalence rate of Clostridium difficle-mediated diarrhea that is secondary to the use of antibiotics particularly the broad-spectrum ones is approximately 250,000 hospitalized patients. That notwithstanding, it accounts for a further 14000 deaths annually, which is the largest proportion of the 23000 deaths annually due to infections in the USA. Such a high prevalence rate has a huge financial implication because the cost of treating persons with infections has further shot up due to the inevitability of diarrhea as a side effect of antibiotic use. For instance, Ebm, Cecconi, Moran, Rhodes, and Rahman (2013) estimated that approximately £13,272.53 was the amount needed to treat an individual with antibiotic-associated diarrhea. Such statistics are worrying given that infections are inevitable across the developmental stages of a human being.
As such, this topic proves to be worthwhile given that a proof of the efficacy of probiotics in preventing the diarrhea conundrum will be of utmost importance to the rectifying of the current situation. That is a fact because upon establishing the use of probiotics comes with this benefit, and its subsequent institutionalization will result in the incidences of diarrhea secondary to antibiotic utilization as well as the cost of treatment reducing significantly.
Statement of Purpose
Of utmost significance to this quality improvement project is the establishment of the efficacy of probiotics in lowering the incidence of the Clostridium difficle-mediated diarrhea in patients on antibiotics. In essence, that is the sole purpose and specific goal of this project. Central to the meeting of this primary goal of the project is specific objectives, which are as follows:
- To determine the efficacy of probiotic use in the prevention of Clostridium difficle associated diarrhea
- To investigate the commonly used probiotic strains in the management Clostridium difficle associated diarrhea
- To establish the adverse effects related to probiotic use in treatment of antibiotic-associated diarrhea mediated by Clostridium difficle
The PICOT question that will facilitate meeting the purpose and specific objectives of the project is:
In patients receiving antibiotics (P) what is the effect of a standing order for probiotics (I) compared to the current practice (C) on the overall incidence of C. Diff (O) over 3 months (T)?
Central to the adopted search strategy were two online databases, namely, PubMed, which was the primary source of studies and COCHRANE Library. In both databases, the PICOT question was of the essence in the identification of the search key terms used in the determination of articles focusing on establishing the efficacy of probiotics use with antibiotics in the management of diarrhea. In the pursuit of literature in the PubMed, the Medical subject heading (MeSH) terms included probiotics, antibiotics, and diarrhea. On the other hand, in the COCHRANE Library search, the general terms used were probiotics, antibiotics, diarrhea and Clostridium difficle. Lastly, for the enhancement of accuracy, the search applied the use of filters such as studies conducted within the last ten years and the English language. 10 out of the possible 200 studies that met the criteria were reviewed. Details of the search strategy are as depicted in the table below.
||Number of articles identified
||Number of articles included
||Number of articles excluded
· “Clostridium difficle”
Summary of Articles Reviewed
Central to this review of the literature, were three key themes, namely, efficacy of probiotic use in the prevention of Clostridium difficle associated diarrhea, commonly used probiotic strains and adverse effects related to probiotic use.
Efficacy of probiotic use in the prevention of Clostridium difficleassociated diarrhea
Five of the reviewed articles looked into the efficacy of probiotics in prevention of antibiotic-associated diarrhea secondary to Clostridium difficle. They established that probiotic use was an effective preventive measure of the Clostridium difficle associated diarrhea as well as reduced its incidence (Angelakis, Merhej, & Raoult, 2013; Preidis & Versalovic, 2009; Sokol, 2014; Fox, Ahuja, Robertson, Ball, & Eri 2014; Dietrich, Kottmann, & Alavi, 2014).
However, Allen, Wareham, Wang, Bradley, Hutchings, Harris, and Mack, (2013) in their study had a contrary opinion that probiotics with a combination of two strains were not effective in either reducing the incidence of the Clostridium difficle associated diarrhea or preventing its occurrence. The quality of evidence in this deduction is high since the researchers utilized a randomized controlled trial to test their hypothesis, which yields high-quality evidence. Despite this study being a high-level quality source of information, its findings may not determine the final say on this issue. That is for sure given that its focus was on the use of probiotics that come as in mixture preparation while the preliminary studies utilized probiotics, which are containing a single strain to test its efficacy.
Commonly used probiotic strains
From the literature, several strains of probiotics played a significant role in either preventing Clostridium difficle associated diarrhea or lowering its incidence. They include Saccharomyces boulardii, Lactobacillus casei DN114001, Clostridium butyricum and Bifidobacterium infantis (Goldenberg, Lytvyn, Steurich, Parkin, Mahant & Johnston, 2015; McFarland, 2015; Issad & Moucari, 2014; Dietrich, Kottmann, & Alavi, 2014).
Furthermore, two more studies depicted that mixtures of the probiotic strains attained better outcomes in patients with Clostridium difficle associated diarrhea. A case in point Ling, Liu, Cheng, Luo, Yuan, Li, and Xiang, (2015) established that a mixture of the Clostridium butyricum combined with Bifidobacterium infantis showed a greater efficacy than a single strain of each of this probiotic agent. Additionally, in another study, it became apparent that a mixture of Lactobacillus acidophilus and Bifidobacterium bifidum, as well as a combination of Lactobacillus acidophilus, Lactobacillus casei and Lactobacillus rhamnosus offered positive outcomes in patients with Clostridium difficle associated diarrhea (McFarland, 2015).
Adverse effects associated with probiotic use
The reviewed studies, which aimed at establishing the safety of probiotics use, observed that they were safe since they had little or no side effects at all. Among the noted side effects for persons on probiotics included abdominal cramps, rash, taste disturbance, increased phlegm, nausea, vomiting, flatulence, abdominal bloating, constipation, chest pain, flatulence, and low appetite (Goldenberg, Lytvyn, Steurich, Parkin, Mahant & Johnston, 2015; Issad & Moucari, 2014). The identified side effects are less likely to occur in immune-competent individuals while the immune-compromised persons are at high risk of exhibiting these side effects (Goldenberg, Lytvyn, Steurich, Parkin, Mahant & Johnston, 2015).
Concisely, from the analysis of literature, it is clear that the use of probiotics in medical practice is one that has not gathered popularity in the health sector. However, this should not be the case given that the studies have shown that incorporation of the probiotics in the management plan can be of great benefit to the patient. Despite the availability of evidence in studies on the efficacy of probiotics in the management of diarrheal infections mediated by Clostridium difficle, there are significant gaps in the literature that are worth noting.
Major Gaps in the Literature
A typical gap in the reviewed literature is that all the studies fail to identify a particular probiotic strain that is effective in the control of Clostridium difficle associated diarrhea. Besides, the studies fail to identify, which of the population stand to benefit most from the inclusion of probiotics in the infection management plan. That notwithstanding, information on the danger of the routine use of the probiotics is also lacking.Last but not the least, the studies fail to identify the dosage of the probiotics that will be effective in preventing the Clostridium difficle associated diarrhea.
Given the existence of the noted gaps in the literature, there is a need for more studies that will help enhance clarity on this issue. The areas of focus that the future studies may devote their efforts include but not limited to the dosage, specific strains and adverse effects of long-term use of probiotics.There is a need for more evidence in these areas if the use of probiotics alongside the antibiotics is to become a mainstay practice for the management of diarrhea in the days to come. Upon institutionalization of probiotics in the treatment protocols of infection, the harsh effects of Clostridium difficle associated diarrhea will becomeavoidable, and the quality of care will improve significantly.
Allen, S. J., Wareham, K., Wang, D., Bradley, C., Hutchings, H., Harris, W., … & Mack, D. (2013). Lactobacilli and bifidobacteria in the prevention of antibiotic-associated diarrhea and Clostridium difficile diarrhea in older inpatients (PLACIDE): a randomised, double-blind, placebo-controlled, multicentre trial. The Lancet, 382(9900), 1249-1257.
Angelakis, E., Merhej, V., & Raoult, D. (2013). Related actions of probiotics and antibiotics on gut microbiota and weight modification. The Lancet Infectious Diseases. https://doi.org/10.1016/S1473-3099(13)70179-8
Centers for Disease Control and Prevention,. (2013). CDC Features – Antibiotic Resistance Threats in the US. Cdc.gov. Retrieved 5 March 2017, from https://www.cdc.gov/features/antibioticresistancethreats/
Dietrich, C. G., Kottmann, T., & Alavi, M. (2014). Commercially available probiotic drinks containing Lactobacillus casei DN-114001 reduce antibiotic-associated diarrhea. World Journal of Gastroenterology: WJG, 20(42), 15837.
Ebm, C., Cecconi, M., Moran, C., Rhodes, A., & Rahman, T. (2013). Cost implication of antibiotic-associated diarrhea and the financial impact of probiotic use in its prevention. Critical Care, 17(S2), P83.
Fox, M. J., Ahuja, K. D., Robertson, I. K., Ball, M. J., & Eri, R. D. (2015). Can probiotic yogurt prevent diarrhea in children on antibiotics? A double-blind, randomised, placebo-controlled study. BMJ open, 5(1), e006474.
Goldenberg, J.Z, Lytvyn, L., Steurich, J., Parkin, P., Mahant, S., & Johnston, B.C. (2015). Probiotics for the prevention of pediatric antibiotic-associated diarrhea. Cochrane Database of Systematic Reviews, 12(CD004827).
Issa, I., & Moucari, R. (2014). Probiotics for antibiotic-associated diarrhea: Do we have a verdict?. World journal of gastroenterology: WJG, 20(47), 17788.
Ling, Z., Liu, X., Cheng, Y., Luo, Y., Yuan, L., Li, L., & Xiang, C. (2015). Clostridium butyricum combined with Bifidobacterium infantis probiotic mixture restores fecal microbiota and attenuates systemic inflammation in mice with antibiotic-associated diarrhea. BioMed research international, 2015.
McFarland, L. V. (2015). Probiotics for the primary and secondary prevention of C. difficile infections: a meta-analysis and systematic review. Antibiotics, 4(2), 160-178.
Preidis, G. A., & Versalovic, J. (2009). Targeting the Human Microbiome With Antibiotics, Probiotics, and Prebiotics: Gastroenterology Enters the Metagenomics Era. Gastroenterology, 136(6), 2015–2031. https://doi.org/10.1053/j.gastro.2009.01.072
Sokol, H. (2014). Probiotics and antibiotics in IBD. Digestive Diseases, 32, 10–17. https://doi.org/10.1159/000367820