Abstract
OBJECTIVESThe 2017 guideline for the prevention of travelers’ diarrhea (TD) by the International Society of Travel Medicine suggested that ‘there is insufficient evidence to recommend the use of commercially available prebiotics or probiotics to prevent or treat TD.’ However, a meta-analysis published in 2007 reported significant efficacy of probiotics in the prevention of TD (summary relative risk [sRR], 0.85, 95% confidence interval [CI], 0.79 to 0.91). This study aimed to synthesize the efficacy of probiotics on TD by updating the meta-analysis of double-blind, placebo-controlled, randomized human trials.METHODSThe search process was conducted by the adaptive meta-analysis method using the ‘cited by’ and ‘similar articles’ options provided by PubMed. The inclusion criteria were double-blind, placebo-controlled, randomized human trials with hypotheses of probiotics as intervention and TD as an outcome. The adaptive meta-analysis was conducted using Stata software using the csi, metan, metafunnel, and metabias options.RESULTSEleven articles were selected for the meta-analysis. The sRR was 0.85 (95% CI, 0.79 to 0.91) and showed statistical significance. There was no heterogeneity (I-squared=28.4%) and no publication bias.CONCLUSIONSProbiotics showed statistically significant efficacy in the prevention of TD.
Highlights
While environmental hygiene has improved more than before, travelers’ diarrhea (TD) remains one of the most important public health issues in the international community as more and more people travel around the world [1]
Among 2 meta-analysis studies cited in the guideline [4,5], Sazawal et al [4] selected 4 articles that published randomized, placebo-controlled trial results [6,7,8,9], and revealed that there was no significant difference in prevention efficacy
Among the 11 selected articles, only two published since 2006 [16,18] presented intention-to-treat (ITT) and per-protocol (PP) separately. In this regard, when the relative risks (RRs) calculated by PP only were applied, there was efficacy in TD prevention while homogeneity was ensured (I-squared= 28.4%; sRR, 0.85; 95% CI, 0.79 to 0.91) (Figure 2)
Summary
While environmental hygiene has improved more than before, travelers’ diarrhea (TD) remains one of the most important public health issues in the international community as more and more people travel around the world [1]. It might be possible to consider administering antibiotics to prevent TD, given that bacteria account for more than 80% of the pathogens that cause. According to the guideline published in 2017 by the International Society of Travel Medicine (ISTM) [1], antibiotics are contraindicated for the prevention of TD among the general population. A meta-analysis published in 2012 [13] included only 4 articles selected by Sazawal et al [4] and demonstrated that their systemic review was incomplete
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