Role of Lactobacillus in the prevention of Clostridium difficile -associated diarrhea: a meta-analysis of randomized controlled trials

Abstract

Background Clostridium difficile-associated diarrhea (CDAD) is a major public health problem because of significant morbidity and mortality, and many clinicians pay attention to Lactobacillus as a potentially effective treatment. The purpose of this meta-analysis was to evaluate the efficacy of Lactobacillus in the prevention of CDAD. Methods The databases MEDLINE, the Cochrane Central Register of Controlled Trials, metaRegister of Controlled Trials, National Institutes of Health, CNKI, VIP, and Wanfang data were searched to locate all reported randomized controlled trials (RCT) from 1990 to December 2012. Only RCT in English and Chinese using Lactobacillus for the prevention of documented CDAD were considered for study inclusion. The data was analyzed by Review Manager and SPSS software. Results Seven placebo-controlled RCTs that evaluated the prevention of CDAD, which included 1486 subjects, accorded with inclusion and exclusion criteria. The mean age of the subjects ranged from 4.15 to 64.75 years and the proportion of male subjects ranged from 42.0% to 59.1%. The total daily dose of Lactobacillus ranged from 1.2×109-1.2×1012 colony-forming units (CFU). A low risk of bias was attributed to two studies and four studies evaluated a medium-level risk of bias. The combined risk ratio (RR) of developing CDAD was significantly lower in subjects who received Lactobacillus compared with subjects who received placebo (RR 0.38, 95% confidence interval (CI) 0.22-0.67). A combination regimen of Lactobacillus acidophilus (L. acidophilus) and Lactobacillus casei (L. casei) (RR 0.05, 95% CI 0.01-0.36) showed significant effect sizes for the prevention of CDAD, while single regimens of Lactobacillus plantarum (L. plantarum) and Lactobacillus rhamnosus (L. rhamnosus) did not. Across all trials, positive significant effects of Lactobacillus were observed in the elderly subgroup (RR 0.05, 95% CI 0.01-0.36). Whether the 1×1012-9×1012 CFU/d Lactobacillus could prevent CDAD significantly or not was unclear. Conclusion There is a sufficient evidence to recommend Lactobacillus (L. acidophilus and L. casei) as a prevention therapy for CDAD.