Probiotics for Clostridium difficile-associated diarrhea:: Focus on Lactobacillus rhamnosus GG and Saccharomyces boulardii

OBJECTIVE: To review the literature on the use of probiotics to treat or prevent recurrences of Clostridium difficile-associated diarrhea (CDAD) by replacing normal gastric flora. DATA SOURCES: PubMed (1970-March 2007) was searched using the terms probiotics, Clostridium difficile, colitis, diarrhea, prevention, and treatment. STUDY SELECTION AND DATA EXTRACTION: Case reports, case series, and clinical trials describing the use of probiotics in the treatment or prevention of recurrences of CDAD as primary outcome were included. DATA SYNTHESIS: A variety of controlled trials, case series, and case reports have evaluated probiotics to treat first or recurrent episodes of CDAD. In addition, a meta-analysis has been conducted to try to determine the role of probiotics in CDAD. In general, most case series and case reports have shown favorable results with Lactobacillus rhamnosus GG or Saccharomyces boulardii. However, other reports have shown lack of benefit. The meta-analysis showed that these probiotics may be useful in treating or preventing recurrences of CDAD. Nonetheless, the heterogeneity of the studies makes definite conclusions difficult. In addition, several cases of bacteremia or fungemia associated with probiotic use have been reported, particularly in the last decade. Patients most commonly affected by these complications are immunosuppressed. Unfortunately, these are also the patients more likely to have severe CDAD or are at risk for recurrences. CONCLUSIONS: Additional experience with and study of probiotics are warranted due to numerous unanswered questions. Given the potential for complications in debilitated and immunosuppressed patients, the risks may outweigh benefits, and rational antibiotic use may be a better option to prevent a first episode or recurrence of CDAD.