Early Intensive Care Unit (ICU) Probiotic Administration Reduces Diarrhea Rates

Abstract

Introduction: ICU patients have numerous risk factors for diarrhea and Clostridium difficile infection (CDI). Although multiple studies have demonstrated efficacy of probiotics toward CDI prevention, society guidelines—ACG, SHEA, IDSA—have not formally recommended probiotics for primary prevention of CDI, in any setting. A recent study that suggested probiotics administered close to antibiotic administration in hospitalized patients could reduce CDI risk had many exclusion criteria and did not include vulnerable ICU patients. We aimed to see whether probiotic administration to ICU patients was associated with less diarrhea and CDI. Methods: All patients ≥18 years who were admitted to the ICU without diarrhea were included. Physicians were educated the month prior by the medical executive committee regarding initiation of VSL#3 probiotic (VSL pharmaceuticals, Inc.; The Living Shield). Pharmacy and nursing staff reminded physicians about probiotic initiation on all patients admitted to the ICU. In the end, ICU physicians decided who to treat, and when. The study, done in a 20-bed ICU in a 300-bed community hospital took place from January to May of 2016. Results: During the study period, 112 of 474 (23.6%) unique patients were placed on probiotics. Demographic and clinical factors among probiotic treated patients with and without diarrhea are shown in Fig. 1. Data for timing of probiotic administration is shown in Fig. 2. Patients with probiotics administered ≤ 2 days in the ICU had significantly lower rates of diarrhea than those administered probiotics >2 days (Fig. 2). Rates of CDI where not associated with timing of probiotics. Multiple logistic regression analysis (Fig. 3) revealed that tube feeds or parental nutrition (OR 6.8, CI 2.3-20.3, P=0.0006) and antibiotics (> 2 drugs) (OR 6.0, CI 2.1-17.1, P=0.0009) increased risk of diarrhea, whereas early probiotics (≤ 2 days in ICU) reduced diarrhea risk (OR 0.29, CI 0.10-0.86, P=0.026).Figure: Demographic and Clinical Factors among Probiotic Treated Patients With (n=44) and Without (n=68) Diarrhea.Figure: Demographic and Clinical Factors Among Probiotic Treated Patients Based on Timing of Probiotic Treatment in ICU.Figure: Multiple Logistic Regression Analysis of Factors Associated with Diarrhea Among Patients Treated with Probiotics in ICU.Conclusion: Though practicing physicians remain reluctant to utilize probiotics in ICU patients, our data suggest that earlier administration of probiotics is associated with lower diarrhea rates. Future studies must be powered to analyze the association between probiotics and CDI rates.