May 03, 2018
3 min read

Probiotics may be ‘viable strategy’ for CDI prevention

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Using probiotics as a prophylaxis for Clostridium difficile was safe and reduced the risk for infection among hospitalized patients by two-thirds, according to a large meta-analysis published in Infection Control and Hospital Epidemiology.

In a separate study, however, researchers reported that adherence to consistent probiotic use at a single tertiary-care medical center was low, which they said demonstrates potential implementation challenges.

“While it’s not a perfect solution for a bacterium that has proven very difficult to prevent and treat, probiotics could offer patients another line of defense,” Bradley C. Johnston, PhD, associate professor of epidemiology at Dalhousie University in Canada, said in a press release.

“We worked with clinical trialists from 12 countries that willingly shared their data with us to conduct what is known as an individual patient data meta-analysis and we demonstrated that we should be considering probiotics as a viable strategy for preventing [C. difficile infection (CDI)] in patients.”

Probiotics reduce CDI

Previous research has shown that probiotics can reduce up to 64% of CDI incidence, according to Johnston and colleagues. However, a lack of evidence and safety concerns have prevented guideline panels from recommending them as a CDI prophylaxis.

To address these issues, Johnston and colleagues examined data from 18 randomized controlled trials that compared the outcomes of 6,851 adult and pediatric patients who either received probiotics, placebo or no treatment (standard of care) to determine whether probiotics were safe and effective against CDI acquisition. They found that probiotics significantly reduced the risk for CDI by approximately two-thirds in both an unadjusted analysis (OR = 0.37; 95% CI, 0.25-0.55) and an analysis adjusted for age, gender, hospitalization status, and antibiotic exposure (OR = 0.35; 95% CI, 0.23-0.55). When stratified by probiotic type, only multispecies probiotics offered significant protection against CDI (OR = 0.33; 95% CI, 0.20-0.56) compared with no probiotic. They were particularly beneficial in hospitals with a CDI incidence rate of at least 5% (P = .007), according to the researchers.

“The observation that probiotic prophylaxis is of greater benefit in populations with moderate-to-high baseline risk should inform site selection in future studies, as should the use of probiotics in clinical settings,” they wrote.

In a safety analysis, the number of serious adverse events were similar in the intervention and control arms (12.4% vs. 12.1%), and none were linked to probiotic use.

Low adherence

In the second study, William Trick, MD, clinician at Cook County Health and Hospitals System, and colleagues performed a before-and-after invention at a 694-bed tertiary-care medical center to assess the impact and feasibility of probiotic use as a primary CDI prevention strategy. After a 12-month baseline period, the researchers prescribed patients on antibiotic therapy to also receive probiotic capsules that contained three Lactobacillus spp: L. acidophilus, L. casei and L. rhamnosus. Certain patients, including those in the neonatal, pediatric and oncology wards, were excluded from the intervention.

Overall, 251 CDI episodes occurred among 360,016 patient days, yielding an incidence rate of 7.0 per 10,000 patient days. CDI incidence was similar during the baseline and intervention periods (6.9 vs. 7.0 per 10,000 patients days). However, there was a significant decrease during the final 6 months of the intervention period compared with the first 6 months, demonstrating a possible delayed benefit (incidence rate ratio = 0.6; 95% CI, 0.4-0.9), according to the researchers.

Medical records showed that missed probiotic doses were common. Only 26% of eligible patients received a probiotic at the right time, highlighting implementation challenges, according to Trick and colleagues. Still, Trick said in the release that probiotics could be a safe and low-cost prevention option for CDI that will likely benefit patients in the long-run.

“The delayed effect is consistent with prior literature and may have been related to poor fidelity to the protocol for probiotic administration and a delayed gradual reduction in environmental contamination,” the researchers concluded. “Our quality improvement intervention in a large hospital encountered substantial implementation challenges. It is critical that such real-world applications are evaluated and reported to guide future quality-improvement research efforts based on the lessons learned. Given the foundation of evidence supporting probiotics to prevent CDI, interventions that achieve better distribution of probiotic and focused environmental cleaning before intervention and control periods are needed to quantify the impact of probiotics on CDI.” – by Stephanie Viguers


Johnston BC, et al. Infect Control Hosp Epidemiol. 2018;doi:10.1017/ice.2018.84.

Trick WE, et al. Infect Control Hosp Epidemiol. 2018;doi:10.1017/ice.2018.76.

Disclosures: Johnston reports receiving a grant from Bio-K Plus International Inc. for work outside of this submitted research. Tick reports receiving compensation from Bio-K Plus for travel to present findings to the company’s advisory board. Please see the studies for a list of all other authors’ relevant financial disclosures.