Vernaya Marina, McAdam Jennifer, Hampton Michelle DeCoux
1Samuel Merritt University, School of Nursing, Oakland, California, USA 2UCSF Centre for Evidence Synthesis and Implementation: a Joanna Briggs Institute Center of Excellence.
JBI Database System Rev Implement Rep. 2017 Jan;15(1):140-164. doi: 10.11124/JBISRIR-2016-003234.
Clostridium difficile bacteria are a leading cause of infectious diarrhea. This is an anaerobic, gram-positive and spore-forming rod responsible for significant morbidity and mortality, especially among elderly hospitalized patients. Standard management of C. difficile-associated diarrhea (CDAD) consists of discontinuing a causative antibiotic, correcting fluid-electrolytes imbalance and initiating an antibiotic treatment for CDAD. Alternative approaches for prevention of CDAD include probiotics. This systematic review will provide a comprehensive, unbiased summary of the available research on the effectiveness of probiotics in decreasing the incidence of infectious diarrhea in elderly hospitalized patients.
To conduct a systematic review to determine the best available evidence related to the effectiveness of probiotics in the prevention of CDAD in elderly hospitalized patients. The review question was: are probiotics effective in decreasing the incidence of CDAD in elderly hospitalized patients?
The current review included studies of participants who were aged 60 years and more and who were residents of acute- and post-acute care facilities undergoing or planning to undergo antibiotic treatment for the management of any infectious conditions, except CDAD.
TYPES OF INTERVENTION(S): The current review included studies that evaluated the effectiveness of probiotics for prevention of CDAD in elderly hospitalized patients in acute- and post-acute care settings compared to usual care.
The current review included studies examining the following outcome measures: incidence or relapse of CDAD. Cases of CDAD were defined by presence of diarrhea and verified by positive results for stool enzyme immunoassay for toxins A and B.
The current review included only experimental study designs including randomized controlled trials.
The search strategy included studies published in English between 1978, when the first case of CDAD was reported, and 2015.
Papers selected for retrieval were assessed by two independent reviewers for methodological quality prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute (JBI).
Data were extracted from papers included in the review using the standardized data extraction tool from the JBI Meta-Analysis of Statistics Assessment and Review Instrument. The data extracted included specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.
Quantitative data were pooled using statistical meta-analysis. Effect sizes were expressed as odds ratios, and their 95% confidence intervals were calculated to determine if probiotic treatment was superior to placebo in reducing CDAD incidence. Heterogeneity was assessed using the standard I statistic.
Five studies were included in the review. The individual study results were conflicting, including non-significant results for four studies and statistically significant results in one that demonstrated fewer cases of CDAD among patients receiving probiotics compared to placebo. The meta-analysis finding indicated that there was no statistically significant difference in CDAD incidence in elderly hospitalized patients taking probiotics when compared to a placebo.
Probiotics were not found to be more effective than placebo for reducing CDAD incidence in elderly hospitalized patients. However, studies that demonstrate improved outcomes must be examined to determine future needs for research. Studies varied with regard to the dose, frequency, method of administration (probiotic drinks versus capsule), length of administration and the number of strains of bacteria administered. Further studies are needed to evaluate the effectiveness of probiotics for CDAD prevention in this population. Clinical trials with evidence-based administration methods and meta-analyses that pool the results of studies with congruent methodologies are needed to enable conclusions to be drawn on the effectiveness of probiotic administration for CDAD prevention.
艰难梭菌是感染性腹泻的主要病因。这是一种厌氧、革兰氏阳性且形成芽孢的杆菌，会导致显著的发病率和死亡率，尤其是在老年住院患者中。艰难梭菌相关性腹泻（CDAD）的标准管理包括停用致病抗生素、纠正水电解质失衡以及开始针对CDAD的抗生素治疗。预防CDAD的替代方法包括益生菌。本系统评价将全面、公正地总结关于益生菌降低老年住院患者感染性腹泻发病率有效性的现有研究。
进行一项系统评价，以确定与益生菌预防老年住院患者CDAD有效性相关的最佳现有证据。评价问题为：益生菌对降低老年住院患者CDAD发病率是否有效？
纳入标准
本次评价纳入了年龄在60岁及以上、居住在急性和亚急性护理机构且正在接受或计划接受抗生素治疗以管理任何感染性疾病（CDAD除外）的参与者的研究。
本次评价纳入了评估在急性和亚急性护理环境中，与常规护理相比，益生菌预防老年住院患者CDAD有效性的研究。
本次评价纳入了检查以下结局指标的研究：CDAD的发病率或复发率。CDAD病例通过腹泻的存在来定义，并通过粪便毒素A和B酶免疫测定的阳性结果进行验证。
本次评价仅纳入了包括随机对照试验在内的实验性研究设计。
检索策略包括1978年（首例CDAD报告年份）至2015年间以英文发表的研究。
在纳入评价之前，使用乔安娜·布里格斯研究所（JBI）的标准化批判性评价工具，由两名独立评审员对选定检索的论文进行方法学质量评估。
使用JBI统计评估和评价工具的元分析标准化数据提取工具，从纳入评价的论文中提取数据。提取的数据包括与评价问题和具体目标相关的干预措施、人群、研究方法和结局的具体细节。
使用统计元分析汇总定量数据。效应大小以比值比表示，并计算其95%置信区间，以确定益生菌治疗在降低CDAD发病率方面是否优于安慰剂。使用标准I统计量评估异质性。
评价纳入了五项研究。各研究结果相互矛盾，四项研究结果无统计学意义，一项研究结果具有统计学意义，该研究表明与安慰剂相比，接受益生菌治疗的患者中CDAD病例较少。元分析结果表明，与安慰剂相比，服用益生菌的老年住院患者CDAD发病率无统计学显著差异。
未发现益生菌在降低老年住院患者CDAD发病率方面比安慰剂更有效。然而，必须对显示出改善结局的研究进行审查，以确定未来的研究需求。各项研究在剂量、频率、给药方法（益生菌饮料与胶囊）、给药时长以及所施用细菌菌株数量方面存在差异。需要进一步研究来评估益生菌在该人群中预防CDAD的有效性。需要采用基于证据的给药方法进行临床试验，并进行元分析以汇总方法一致的研究结果，从而能够就益生菌给药预防CDAD 的有效性得出结论。
