Leslie M. Martin, MD

Clinical Question: Does the use and timing of probiotics in hospitalized adult patients with Clostridium difficile infection (CDI) improve clinical outcomes?

Background: The incidence of CDI in hospitalized patients has increased significantly over the past years, resulting in significant morbidity and mortality. Improved prevention of CDI could have substantial public health benefits.

Study design: Systematic review and metaregression analysis.

Setting: 19 studies meeting inclusion criteria.

Synopsis: Computerized bibliography databases were searched for randomized controlled trials (RCTs) evaluating probiotic effects on CDI in hospitalized adults taking antibiotics.

Comprising 6261 subjects, 19 RCTs were analyzed. The incidence of CDI was lower in the probiotic cohort than in the control group (1.6% vs. 3.9%; P less than 0.001). The pooled relative risk of CDI in probiotic users was 0.42 (95% CI, 0.30-0.57). Metaregression analysis demonstrated that probiotics were significantly more effective if given closer to the first antibiotic dose, with a decrease in efficacy for every day of delay in starting probiotics (P = .04). Probiotics given within 2 days of antibiotic initiation produced a greater reduction of risk for CDI (RR, 0.32; 95% CI, 0.22-0.48) than later administration (RR, 0.70; 95% CI, 0.40-1.23; P = .02). There was no increased risk for adverse events among patients receiving probiotics.

Limitations included high risk of bias because of missing data, attrition, restricted patient population, lack of placebo, and conflict of interest.

Bottom Line: Administration of probiotics soon after the first dose of antibiotic reduces the risk of CDI by more than 50% in hospitalized adults without any increased risk of adverse events.

Reference: Shen NT, Maw A, Tmanova LL et al. Timely use of Probiotics in Hospitalized Adults Prevents Clostridium difficile Infection: A Systematic Review with Meta-Regression Analysis. Gastroenterology. Published on 9 Feb 2017. doi: 10.1053/j.gastro.2017.02.003.
 

Dr. Martin is clinical professor in the division of hospital medicine, department of medicine, University of California, San Diego.

Clinical Question: Does the use and timing of probiotics in hospitalized adult patients with Clostridium difficile infection (CDI) improve clinical outcomes?

Background: The incidence of CDI in hospitalized patients has increased significantly over the past years, resulting in significant morbidity and mortality. Improved prevention of CDI could have substantial public health benefits.

Study design: Systematic review and metaregression analysis.

Setting: 19 studies meeting inclusion criteria.

Synopsis: Computerized bibliography databases were searched for randomized controlled trials (RCTs) evaluating probiotic effects on CDI in hospitalized adults taking antibiotics.

Comprising 6261 subjects, 19 RCTs were analyzed. The incidence of CDI was lower in the probiotic cohort than in the control group (1.6% vs. 3.9%; P less than 0.001). The pooled relative risk of CDI in probiotic users was 0.42 (95% CI, 0.30-0.57). Metaregression analysis demonstrated that probiotics were significantly more effective if given closer to the first antibiotic dose, with a decrease in efficacy for every day of delay in starting probiotics (P = .04). Probiotics given within 2 days of antibiotic initiation produced a greater reduction of risk for CDI (RR, 0.32; 95% CI, 0.22-0.48) than later administration (RR, 0.70; 95% CI, 0.40-1.23; P = .02). There was no increased risk for adverse events among patients receiving probiotics.

Limitations included high risk of bias because of missing data, attrition, restricted patient population, lack of placebo, and conflict of interest.

Bottom Line: Administration of probiotics soon after the first dose of antibiotic reduces the risk of CDI by more than 50% in hospitalized adults without any increased risk of adverse events.

Reference: Shen NT, Maw A, Tmanova LL et al. Timely use of Probiotics in Hospitalized Adults Prevents Clostridium difficile Infection: A Systematic Review with Meta-Regression Analysis. Gastroenterology. Published on 9 Feb 2017. doi: 10.1053/j.gastro.2017.02.003.
 

Dr. Martin is clinical professor in the division of hospital medicine, department of medicine, University of California, San Diego.

Clinical Question: Does the use and timing of probiotics in hospitalized adult patients with Clostridium difficile infection (CDI) improve clinical outcomes?

Background: The incidence of CDI in hospitalized patients has increased significantly over the past years, resulting in significant morbidity and mortality. Improved prevention of CDI could have substantial public health benefits.

Study design: Systematic review and metaregression analysis.

Setting: 19 studies meeting inclusion criteria.

Synopsis: Computerized bibliography databases were searched for randomized controlled trials (RCTs) evaluating probiotic effects on CDI in hospitalized adults taking antibiotics.

Comprising 6261 subjects, 19 RCTs were analyzed. The incidence of CDI was lower in the probiotic cohort than in the control group (1.6% vs. 3.9%; P less than 0.001). The pooled relative risk of CDI in probiotic users was 0.42 (95% CI, 0.30-0.57). Metaregression analysis demonstrated that probiotics were significantly more effective if given closer to the first antibiotic dose, with a decrease in efficacy for every day of delay in starting probiotics (P = .04). Probiotics given within 2 days of antibiotic initiation produced a greater reduction of risk for CDI (RR, 0.32; 95% CI, 0.22-0.48) than later administration (RR, 0.70; 95% CI, 0.40-1.23; P = .02). There was no increased risk for adverse events among patients receiving probiotics.

Limitations included high risk of bias because of missing data, attrition, restricted patient population, lack of placebo, and conflict of interest.

Bottom Line: Administration of probiotics soon after the first dose of antibiotic reduces the risk of CDI by more than 50% in hospitalized adults without any increased risk of adverse events.

Reference: Shen NT, Maw A, Tmanova LL et al. Timely use of Probiotics in Hospitalized Adults Prevents Clostridium difficile Infection: A Systematic Review with Meta-Regression Analysis. Gastroenterology. Published on 9 Feb 2017. doi: 10.1053/j.gastro.2017.02.003.
 

Dr. Martin is clinical professor in the division of hospital medicine, department of medicine, University of California, San Diego.

Clinical Question: In patients hospitalized for a lower gastrointestinal bleeding (LGIB), does an urgent colonoscopy (less than 24 hours after admission) result in any clinical benefits, compared with waiting for an elective colonoscopy?

Background: LGIB is a common cause of morbidity and mortality, often requiring hospitalization. While colonoscopy is necessary for appropriate work-up and treatment, it remains unclear if time to colonoscopy (urgent vs. elective) confers any clinical benefit in hospitalized patients.

Study Design: Systematic review and meta-analysis.

Setting: Twelve studies meeting inclusion criteria.

Synopsis: Computerized bibliography databases were searched for appropriate studies, and 12 met inclusion criteria, resulting in a total sample size of 10,172 patients in the urgent colonoscopy arm and 14,224 patients in the elective colonoscopy.

Outcome measures included bleeding source identified on colonoscopy, therapeutic endoscopic interventions performed, patients requiring blood transfusions, rebleeding, adverse events, and mortality.

Urgent colonoscopy was associated with increased use of endoscopic therapeutic intervention (relative risk, 1.70; 95% CI, 1.08-2.67). There were no significant differences in bleeding source localization (RR, 1.08; 95% CI, 0.92-1.25), adverse event rates (RR, 1.05; 95% CI, 0.65-1.71), rebleeding rates (RR, 1.14; 95% CI, 0.74-1.78), transfusion requirement (RR, 1.02; 95% CI, 0.73-1.41), or mortality (RR, 1.17; 95% CI, 0.45-3.02) between urgent and elective colonoscopy.

Limitations of the study comprise of inclusion of small number of studies, underpowered statistical analysis, and possible variation in quality assessment of articles evaluated.

Bottom Line: Urgent colonoscopy is safe and usually well tolerated in hospitalized patients with LGIB, but, compared with elective colonoscopy, there is no clear evidence it alters important clinical outcomes.

Reference: Kouanda AM, Somsouk M, Sewell JL, Day LW. Urgent colonoscopy in patients with lower GI bleeding: A systematic review and meta-analysis. Gastrointest Endosc. Published online Feb 4, 2017. doi: 10.1016/j.gie.2017.01.035.

Dr. Martin is clinical professor in the division of hospital medicine, department of medicine, University of California, San Diego.

Clinical Question: In patients hospitalized for a lower gastrointestinal bleeding (LGIB), does an urgent colonoscopy (less than 24 hours after admission) result in any clinical benefits, compared with waiting for an elective colonoscopy?

Background: LGIB is a common cause of morbidity and mortality, often requiring hospitalization. While colonoscopy is necessary for appropriate work-up and treatment, it remains unclear if time to colonoscopy (urgent vs. elective) confers any clinical benefit in hospitalized patients.

Study Design: Systematic review and meta-analysis.

Setting: Twelve studies meeting inclusion criteria.

Synopsis: Computerized bibliography databases were searched for appropriate studies, and 12 met inclusion criteria, resulting in a total sample size of 10,172 patients in the urgent colonoscopy arm and 14,224 patients in the elective colonoscopy.

Outcome measures included bleeding source identified on colonoscopy, therapeutic endoscopic interventions performed, patients requiring blood transfusions, rebleeding, adverse events, and mortality.

Urgent colonoscopy was associated with increased use of endoscopic therapeutic intervention (relative risk, 1.70; 95% CI, 1.08-2.67). There were no significant differences in bleeding source localization (RR, 1.08; 95% CI, 0.92-1.25), adverse event rates (RR, 1.05; 95% CI, 0.65-1.71), rebleeding rates (RR, 1.14; 95% CI, 0.74-1.78), transfusion requirement (RR, 1.02; 95% CI, 0.73-1.41), or mortality (RR, 1.17; 95% CI, 0.45-3.02) between urgent and elective colonoscopy.

Limitations of the study comprise of inclusion of small number of studies, underpowered statistical analysis, and possible variation in quality assessment of articles evaluated.

Bottom Line: Urgent colonoscopy is safe and usually well tolerated in hospitalized patients with LGIB, but, compared with elective colonoscopy, there is no clear evidence it alters important clinical outcomes.

Reference: Kouanda AM, Somsouk M, Sewell JL, Day LW. Urgent colonoscopy in patients with lower GI bleeding: A systematic review and meta-analysis. Gastrointest Endosc. Published online Feb 4, 2017. doi: 10.1016/j.gie.2017.01.035.

Dr. Martin is clinical professor in the division of hospital medicine, department of medicine, University of California, San Diego.

Clinical Question: In patients hospitalized for a lower gastrointestinal bleeding (LGIB), does an urgent colonoscopy (less than 24 hours after admission) result in any clinical benefits, compared with waiting for an elective colonoscopy?

Background: LGIB is a common cause of morbidity and mortality, often requiring hospitalization. While colonoscopy is necessary for appropriate work-up and treatment, it remains unclear if time to colonoscopy (urgent vs. elective) confers any clinical benefit in hospitalized patients.

Study Design: Systematic review and meta-analysis.

Setting: Twelve studies meeting inclusion criteria.

Synopsis: Computerized bibliography databases were searched for appropriate studies, and 12 met inclusion criteria, resulting in a total sample size of 10,172 patients in the urgent colonoscopy arm and 14,224 patients in the elective colonoscopy.

Outcome measures included bleeding source identified on colonoscopy, therapeutic endoscopic interventions performed, patients requiring blood transfusions, rebleeding, adverse events, and mortality.

Urgent colonoscopy was associated with increased use of endoscopic therapeutic intervention (relative risk, 1.70; 95% CI, 1.08-2.67). There were no significant differences in bleeding source localization (RR, 1.08; 95% CI, 0.92-1.25), adverse event rates (RR, 1.05; 95% CI, 0.65-1.71), rebleeding rates (RR, 1.14; 95% CI, 0.74-1.78), transfusion requirement (RR, 1.02; 95% CI, 0.73-1.41), or mortality (RR, 1.17; 95% CI, 0.45-3.02) between urgent and elective colonoscopy.

Limitations of the study comprise of inclusion of small number of studies, underpowered statistical analysis, and possible variation in quality assessment of articles evaluated.

Bottom Line: Urgent colonoscopy is safe and usually well tolerated in hospitalized patients with LGIB, but, compared with elective colonoscopy, there is no clear evidence it alters important clinical outcomes.

Reference: Kouanda AM, Somsouk M, Sewell JL, Day LW. Urgent colonoscopy in patients with lower GI bleeding: A systematic review and meta-analysis. Gastrointest Endosc. Published online Feb 4, 2017. doi: 10.1016/j.gie.2017.01.035.

Dr. Martin is clinical professor in the division of hospital medicine, department of medicine, University of California, San Diego.