Evidence-Based Practice Critically Appraised Topic

Running head: DIARRHEA AND PROBIOTIC USE / 1

Diarrhea & Probiotic Use

Stacy A. Cederstrom BSN, RN, FNP-s

University of Mary

March 7, 2014

Evidenced Based Practice Critically Appraised Topic: Diarrhea & Probiotic Use

Clinical Scenario

A 76 year old, Caucasian male presents with recurrent episodes of diarrhea for the past 6 months. Patient has history of two episodes of prescribed antibiotic use for pneumonia in past 6 months. Stool: positive for Clostridium difficile infection. Results indicate Clostridium difficile associated diarrhea.

Clinical Question

In patients with recurrent diarrhea related to infection or Clostridium difficile, do probiotics, compared to no treatment, reduce incidence of diarrhea related infection?

Articles

Allen, S. J., Martinez, E. G., Gregorio, G. V., & Dans L. F. (2010). Probiotics for treating acute

infectious diarrhoea. Cochrane Database of Systematic Reviews, Issue 12.

doi: 10.1002/14651858.CD003048.pub3

Goldenberg, J. Z., Ma, S. S., Saxton, J. D., Martzen, M. R., Vandvik, P. O., Thorlund, K., …

Johnston, B. C. (2013). Probiotics for the prevention of Clostridium difficile-associated diarrhea in adults and children. Cochrane Database of Systematic Reviews, (5).

doi: 10.1002/14651858.CD006095.pub3

Summary and Appraisal of Key Evidence

Study 1:

Allen, Martinez, Gregorio, & Dans, (2010) state that probiotics may offer a safe intervention in acute infectious diarrhea to reduce the duration and severity of the illness. A trial was registered in 2010 by the Cochrane Infectious Diseases group. Randomized and quasi-randomized controlled trials comparing specified probiotic agents with placebo or no probiotic in people with acute diarrhea that is proven or presumed to be caused by infectious agents. Primary outcomes reviewed were the mean duration of diarrhea, stool frequency on day two after intervention and ongoing diarrhea on day four. Sixty-three studies met required criteria. There were a total of 8014 participants. The trials found an average of significant mean duration of diarrhea 24.76 hours with 95% confidence interval 15.9 to 33.6 hours. It was found that diarrhea lasting greater than or equal to four days and stool frequency on day two had a mean difference of 0.80;0.45 to 1.14;n=2751. Level of evidence is level 1, study is valid and reliable.

Study 2:

Goldenberg et al. (2013)…. state; disturbances can occur in the gastrointestinal flora of the patient who is prescribed antibiotics. Reduction in resistance then follows by organisms such as Clostridium difficile (C. difficile). Probiotics are live organisms thought to balance out the gastrointestinal flora. In order to assess the efficacy and safety of probiotics for preventing of C. difficile infections, a Cochrane Review was conducted. Randomized controlled trials investigating probiotics for prevention of C. difficile were selected. Meta-analysis of 23 random controlled trials including 4213 participants, moderate quality evidence found that use of probiotics reduced risk of C. difficile infection by 64%. Level of evidence is level 1, study is valid and reliable.

Results

Allen, Martinez, Gregorio, & Dans (2010) state in their Cochrane collaboration; alongside rehydration therapy, probiotics appear to be safe and have beneficial effects in shortening the duration of acute infectious diarrhea as well as frequency of stools. They also found that vomiting occurred less frequently with the use of probiotics than the control groups.

Goldenberg et al. (2013)… state there is overall evidence suggesting use of probiotics reduce the incidence of C. difficile infection when taking during antibiotic use. They also state there is a protective affect that occurs within the intestine during use of probiotics. Probiotics also appear to be safe in immunocompromised patients.

Areas of Conflict

The Cochrane reviews did not distinguish the particular probiotics used in the studies. Detailed and defined treatment dosages and regimens were also not identified. More research needs to be done to determine a guide for particular probiotic regimens or specific types of probiotics for infectious diarrhea. More research must also be conducted on optimal dosage, starting point and end of treatment while taking antibiotics. Specific organisms need to be identified for benefits of use with infectious diarrhea to minimize symptomology with probiotics.

Clinical Bottom Line:

Probiotics have been found to be affective in decreasing the duration of infectious diarrhea as well as decreasing vomiting associated with diarrhea. Probiotics have been found safe to use in patients who are taking a course of antibiotics as well in immunocompromised patients.

Implications for nursing practice: