November 21, 2012Volume 7 - Issue 47   

DynaMed Weekly Update

For the week ending November 16, 2012

Last week 451 articles were evaluated via DynaMed's Systematic Literature Surveillance and 259 were added to DynaMed content.   


Based on the editors' criteria of selecting "articles most likely to change clinical practice," one article of significant interest was selected for the DynaMed Weekly Update.

Feature Article

Probiotics Reduce Risk of Clostridium difficile-Associated Diarrhea in Patients Taking Antibiotics


Diarrhea is a common side effect of antibiotic treatment, which disturbs the balance of bacteria in the gut and may impair the colonization resistance of gastrointestinal flora. Probiotics have previously been shown to reduce rates of antibiotic-associated diarrhea in a large number of trials and systematic reviews (e.g. Aliment Pharmacol Ther 2012 Jun;35(12):1355, Cochrane Database Syst Rev 2011 Nov 9;(11):CD004827). Of particular concern is the specific risk of Clostridium difficile infection, which may cause not just diarrhea, but also colitis and death. A new systematic review of 20 randomized trials evaluated the effects of probiotic prophylaxis specifically on the prevention of C. difficile-associated diarrhea.


A total 3,818 children and adults who were taking antibiotics were randomized to probiotic prophylaxis vs. placebo or no treatment. Probiotic species included Lactobacillus (L. acidophilusL. caseiL. plantarumL. rhamnosus GG), Saccharomyces (S. boulardiiS. thermophiles), and Bifidobacterium, with combinations of species in 7 trials. Probiotic treatment lasted for the duration of antibiotic treatment in 7 trials and for up to 14 days after end of antibiotics in the remaining trials.  The probiotic dose was > 10 billion colony-forming units/day in 18 trials. Follow-up ranged from the last day of treatment to 3 months.


In the overall analysis, probiotic treatment significantly reduced the incidence of C. difficile-associated diarrhea compared to control (relative risk 0.34, 95% CI 0.24-0.49), The median rate of C. difficile-associated diarrhea in controls was 5%, giving an NNT of 27-40 for probiotic treatment (level 1 [likely reliable] evidence). Probiotics were also associated with reduced incidence of C. difficile-associated diarrhea in children in an analysis of 3 trials with 605 patients (relative risk 0.4, 95% CI 0.17-0.96, NNT 20-417 with diarrhea in 6% of controls). In analyses of specific probiotic species, the incidence of C. difficile-associated diarrhea was significantly reduced with S. boulardii in analysis of 6 trials with 1,232 patients and with a combination of L. acidophilus and L. casei in analysis of 3 trials with 781 patients. There were no significant differences in adverse events (Ann Intern Med 2012 Nov 13 early online).


For more information, see the Probiotics to prevent antibiotic-associated diarrhea, Clostridium difficile infection, and Clostridium difficile infection in children topics in DynaMed.

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DynaMed Events  

American Society of Hematology (ASH) Annual Meeting and Exposition, December 8th - 11th, 2012


Senior Deputy Editor Alan Ehrlich will be attending the American Society of Hematology Annual Meeting and Exposition held at the Georgia World Congress Center in Atlanta, Georgia. Representatives will be available at the DynaMed booth to discuss peer review, mobile access, and free trial information.


Visit the American Society of Hematology's website to learn more about the event and for registration information.

Call for Peer Reviewers

We are currently seeking reviewers for:   

Enterohemorrhagic Escherichia coli infection 

Small bowel obstruction 

Learn more about the DynaMed Contribution Opportunities:

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Editorial Policies for Reviewers 

About DynaMed Weekly Update

Prepared by the clinician members of the DynaMed Editorial Team, DynaMed Weekly Update is a compilation of one to five articles selected from DynaMed's Systematic Literature Surveillance as articles most likely to change clinical practice.

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CME Information


0.25 AMA PRA Category I Credit(s)™
Family Physicians: 0.25 Prescribed credits
Nurse Practitioners: 0.25 Contact hours
Release Date: November 21, 2012
Expiration Date: November 21, 2013
Estimated Completion Time:
15 minutes
There is no fee for this activity.

To Receive Credit 
In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.

Program Overview

Learning Objectives


Upon successful completion of this educational program, the reader should be able to:


1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.


Faculty Information
Alan Ehrlich, MD - Assistant Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company

Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.


No commercial support has been received for this activity.

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ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: Enduring Material activity, DynaMed Weekly Update, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 7, 2012. Term of approval is for one year from this date with the option of yearly renewal. Each Weekly Update is worth .25 Prescribed credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.


AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners.


Program ID: 1210392L

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