Open Access

Response to “Reassessing the death risk related to probiotics in critically ill patients”

Critical Care201721:43

https://doi.org/10.1186/s13054-017-1618-0

Published: 27 February 2017

The original article was published in Critical Care 2016 20:388

We would like to thank Dr. Maraolo for his valuable and careful analysis [1] of the data of our recently published systematic review and meta-analysis on probiotic and synbiotic therapy in the critically ill [2]. As Dr. Maraolo has observed we have made an error in the calculation of the pooled risk ratio (RR) and 95% confidence interval (CI) for the effect of probiotics on hospital mortality. When we abstracted mortality data from the Besselink et al. [3] study we included correct data in both arms (24 of 152 and 9 of 144 patients in the probiotic and placebo groups, respectively). Nonetheless, we made a mistake creating the forest plot. Please, accept our sincere apologies.

Currently, after including the correct data from the Besselink et al. study using the random effect model in the software RevMan 5.3 (Cochrane IMS, Oxford, UK), we found that the revised effect of probiotics and synbiotics therapy on overall mortality is 1.02 (95% CI 0.85,1.22; p = 0.83, I2 = 0%; Fig. 1). Notwithstanding, at this point we respectfully disagree with Dr. Maraolo. Certainly, after reassessing the RR this new result does not change the direction of the effect against the use of probiotics in the critically ill. Our previous data showed that the RR was 0.98 with a CI similar to the present one (0.85, 1.22). Moreover, the p value was 0.83 and we cannot thus affirm that a trend against probiotics on mortality exists, as we defined trend with a p value <0.10. So far, clinical trials evaluating the effects of probiotics (excluding Saccharomyces boulardii, which should not be considered as a probiotic in the critical care setting) [4] in different ICU patient populations have documented safety and clinical benefits, as we recently demonstrated in our systematic review.
Fig. 1

Effect of Probiotics and Synbiotics Therapy on Hospital Mortality

Having said that, the conclusion of our meta-analysis remains unchanged. According to our findings probiotic therapy may be associated with a significant reduction in overall new infections, including new episodes of ventilator-associated pneumonia. However, no benefits in terms of reduction in mortality or another relevant clinical outcome for critically ill patients have been pointed out.

Notes

Abbreviations

CI: 

Confidence interval

RR: 

Risk ratio.

Declarations

Acknowledgements

Not applicable.

Funding

No funding was needed for this letter.

Availability of data and materials

Not applicable.

Authors´ contribution

WM and PW wrote and edited the letter. Both authors read and approved the final version of the manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable.

Ethical approval and consent to participate

Not applicable.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Critical Care, Intensive Care Unit, Hospital de Clínicas (University Hospital). Faculty of Medicine, Universidad de la República (UdelaR)
(2)
Department of Anesthesiology and Surgery, Duke University School of Medicine, Duke Clinical Research Institute

References

  1. Maraolo AE. Reassessing the death risk related to probiotics in critically ill patients. Crit Care. 2016;20:338.View ArticleGoogle Scholar
  2. Manzanares W, Lemieux M, Langlois PL, Wischmeyer PE. Probiotic and synbiotic therapy in critical illness: a systematic review and meta-analysis. Crit Care. 2016;20:262.View ArticlePubMed CentralGoogle Scholar
  3. Besselink MG, van Santvoort HC, Buskens E, Boermeester MA, van Goor H, Timmerman HM, Nieuwenhuijs VB, Bollen TL, van Ramshorst B, Witteman BJ, Rosman C, Ploeg RJ, Brink MA, Schaapherder AF, Dejong CH, Wahab PJ, van Laarhoven CJ, Van der Harst E, van Eijck CH, Cuesta MA, Akkermans LM, Gooszen HG, Dutch Acute Pancreatitis Study Group. Probiotic prophylaxis in predicted severe acute pancreatitis: a randomised, double-blind,placebo-controlled trial. Lancet. 2008;371:651–9.View ArticlePubMedGoogle Scholar
  4. Urben LM, Wiedmar J, Boettcher E, Cavallazzi R, Martindale RG, McClave SA. Bugs or drugs: are probiotics safe for use in the critically ill? Curr Gastroenterol Rep. 2014;16:388.View ArticlePubMedGoogle Scholar

Copyright

© The Author(s). 2017

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