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Impact of the Administration of Probiotics on Mortality in Critically Ill Adult Patients: A Meta-Analysis of Randomized Controlled Trials
Study Question: Is there significant evidence that probiotics are beneficial in critically ill patients?
Study Description: This study is a meta-analysis reviewing randomized controlled trials (RCTs) published from 1950 to May 2012 and were included if they contained the following: critically ill adults; probiotic-to-placebo comparison; and consideration of all-cause mortality in the ICU as the primary outcome. Secondary outcomes included: all-cause hospital mortality, incidence of ICU-acquired infections (total and split into pneumonia and catheter-related blood stream infections [CR-BSIs]), incidence of diarrhea, duration of mechanical ventilation, and ICU and hospital length of stay (LOS).
Results: Thirteen RCTs were included in the meta-analysis from the original search results. Most patients were in medical-surgical ICUs, although five RCTs included only surgical or trauma patients. The treatment regimen was a single or combination of probiotic strains, all of which included Lactobacillus. The primary outcome of mortality in the ICU was studied in nine of the RCTs, and probiotics did not appear to have any effect (OR 0.85; 95% CI 0.63-1.15). Heterogeneity (I2 = 0%) and publication bias appeared to be absent. Similarly, probiotics had no effect on hospital mortality (OR 0.9; 95% CI 0.65-1.24) nor on the incidence of ICU-acquired infections overall. However, when broken into specific infection types, probiotics reduced the incidence of ICU-acquired pneumonia (OR 0.54; 95% CI 0.42-0.79). Only 3 RCTs reported on the incidence of ICU-acquired CR-BSIs with no difference found using a random-effects model. The incidence of diarrhea, duration of mechanical ventilation, and hospital LOS were not influenced by the probiotics. However, ICU length of stay was shortened for patients on probiotics vs. control patients in seven RCTs (-1.49 days; 95% CI -2.12 to -0.87). Probiotics appear to be safe and caused no related infectious complications or ischemic bowel.
Conclusion(s): The use of probiotics, Lactobacillus specifically, is beneficial in critically ill patients.
Perspective: There appeared to be no benefit on ICU or all-cause hospital mortality. Although patients receiving probiotics did have a lower incidence of ICU acquired pneumonia and ICU LOS, these secondary and subgroup findings merit a degree of caution. The findings, however, suggest that there are no significant safety concerns associated with Lactobacillus probiotics in ICU patients.