Efetividade dos probióticos na prevenção de infecções em idosos: revisão sistemática e metanálise
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Data
2017-05-23
Autores
Wachholz, Patrick Alexander [UNESP]
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Editor
Universidade Estadual Paulista (Unesp)
Resumo
O impacto das doenças infecciosas na pessoa idosa extrapola os domínios clínico, econômico e social: à redução da sobrevida somam-se o elevado risco de declínio funcional, maior demanda por cuidados e significativa piora na qualidade de vida. Intervenções que possam prevenir infecções em idosos ou reduzir seu impacto podem agregar valor à estratégias bem embasadas, como a vacinação, nutrição e medidas de higiene e proteção à saúde. Os probióticos são microrganismos vivos que, quando consumidos em quantidades suficientes, conferem benefícios à saúde do hospedeiro. Evidências sugerem que o consumo de probióticos possa associar-se à redução na duração média e frequência dos episódios de infecções de vias aéreas superiores e diarreias infecciosas, porém os resultados de ensaios clínicos realizados com idosos são controversos. Esta revisão sistemática e metanálise objetiva avaliar a efetividade e segurança dos probióticos na prevenção de infecções em idosos. Utilizando estratégias sistematizadas, buscou-se por ensaios clínicos disponíveis na literatura até 30 de Dezembro de 2016, que tivessem incluído preferencialmente pessoas com mais de 65 anos, comparando o uso de probióticos com placebo. Dois autores acessaram de modo independente a elegibilidade e qualidade dos estudos, e extraíram os dados utilizando os procedimentos metodológicos recomendados pela Colaboração Cochrane. Os principais desfechos de eficácia incluíram a prevenção de infecções, a qualidade de vida, a mortalidade e a duração média por episódio de infecção, enquanto os desfechos de segurança incluíram os eventos adversos. Os resultados foram expressos como razões de risco, diferença média ou diferença média padronizada, conforme apropriado, com intervalos de confiança de 95%, utilizando metanálises de efeitos aleatórios, quando pelo menos três estimativas estiverem disponíveis por desfecho. Quando identificou-se substancial heterogeneidade, foram investigadas as causas potenciais, incluindo análises de subgrupos. Para avaliar a qualidade da evidência para cada um dos desfechos de interesse utilizamos a ferramenta GRADE. Resultados principais: A busca resultou em 5.036 citações; excluídas as duplicatas e aplicados os critérios de elegibilidade, 15 estudos foram incluídos. Estes avaliaram 5.916 participantes, com uma idade média de 75,21 anos, durante uma mediana de seguimento de 319 dias (204,75—631,50). O efeito dos probióticos na ocorrência de infecções não diferiu daquele observado para o placebo (13 estudos, 5.820 participantes: RR 0,90, IC95% 0,76—1,08, I2=24%, moderada qualidade da evidência). Não foram observadas diferenças significativas nas estimativas de efeito quando analisados os estudos que incluíram apenas pessoas idosas, bem como nas análise de subgrupos ou de sensibilidade. Os efeitos do consumo de probióticos na ocorrência de eventos adversos e mortalidade geral não foram estatisticamente diferentes daqueles observados para o placebo (RR 1,01, IC95%, 0,91—1,12; I2=0%, moderada qualidade da evidência e RR 1,09, IC95% 0,70—1,72; I2=5%, muito baixa qualidade da evidência, respectivamente). Por fim, a duração média dos episódios de infecção não diferiu entre os idosos que consumiram probióticos quando comparados aos que usaram placebo (sete estudos, 1.406 participantes, MD -0,35, IC95% -1,57—0,87, I2=86%, baixa qualidade da evidência). Análises de subgrupo não foram capazes de reduzir a heterogeneidade deste desfecho, e análise de sensibilidade não modificaram as estimativas de efeito. Conclusões: A utilização de probióticos com o objetivo de prevenir infecções ou reduzir a duração média de seus episódios não parece diferir do placebo nesta população.
The burden of infectious diseases on the elderly goes beyond the clinical, economic and social domains: one can add to the reduction on survival higher risk of functional decline, greater demand for care and significant worsening on quality of life. Interventions that could prevent infections in the elderly, or reduce their impact, can add value to well-founded strategies such as vaccination, nutrition, hygiene and health protection measures. Probiotics are living microorganisms that, when consumed in sufficient amounts, confer benefits to the health of the host. Evidence suggests that probiotic consumption may be associated with a reduction in the mean duration and occurrence of episodes of upper respiratory infections and infectious diarrhea, but the results of clinical trials conducted with older patients are controversial. This systematic review and meta-analysis aimed to evaluate the effectiveness and safety of probiotics in the prevention of infections in the elderly. Using systematized strategies, we searched for clinical trials available in the literature up to December 30, 2016, which had preferably included people over 65 years of age, comparing the use of probiotics with placebo. Two authors independently assessed the eligibility and quality of the studies, and extracted the data using the methodological procedures recommended by the Cochrane Collaboration. The main efficacy outcomes included infection prevention, quality of life, and mean duration per episode of infection, while safety outcomes included adverse events and mortality. The results were expressed as risk ratios, mean difference or standardized mean difference, as appropriate, with 95% confidence intervals using random effects metaanalysis, pooled where more than three estimates were available. When substantial heterogeneity was identified, potential causes were investigated, including subgroup analyzes. We used the GRADE tool to evaluate the quality of the evidence for each of the outcomes of interest. Main results: The search resulted in 5,036 citations. Excluding duplicates and applying the eligibility criteria, 15 studies were included. They evaluated 5,916 participants, with a mean age of 75.21 years, during a median follow-up of 319 days (204,75-631,50). The effect of probiotics on the occurrence of infections did not differ from that observed for placebo (13 studies, 5,820 participants: RR 0.90, 95% CI 0.76-1.08, I2 = 24%, moderate quality of evidence). No significant differences in effect estimates were observed when analyzing studies that included only elderly people, as well as in subgroup or sensitivity analyzes. The effects of probiotic consumption on the occurrence of adverse events and overall mortality were not statistically different from those observed for placebo (RR 1.01, 95% CI, 0.91-1.12, I2 = 0%, moderate quality of evidence, and RR 1.09, 95% CI 0.70-1.72, I2 = 5%, very low quality of evidence, respectively). Finally, the mean duration of infection episodes did not differ between the elderly who consumed probiotics compared to those who used placebo (seven studies, 1,406 participants, MD -0.35, 95% CI -1.57-0.87, I2 = 86%, poor quality of evidence). The subgroup analyzes were not able to reduce the heterogeneity of these outcomes; sensitivity analyzes did not modified the results. CONCLUSIONS: The use of probiotics did not appear to prevent infections or reduce the average duration of their episodes whean compared to placebo in older person.
The burden of infectious diseases on the elderly goes beyond the clinical, economic and social domains: one can add to the reduction on survival higher risk of functional decline, greater demand for care and significant worsening on quality of life. Interventions that could prevent infections in the elderly, or reduce their impact, can add value to well-founded strategies such as vaccination, nutrition, hygiene and health protection measures. Probiotics are living microorganisms that, when consumed in sufficient amounts, confer benefits to the health of the host. Evidence suggests that probiotic consumption may be associated with a reduction in the mean duration and occurrence of episodes of upper respiratory infections and infectious diarrhea, but the results of clinical trials conducted with older patients are controversial. This systematic review and meta-analysis aimed to evaluate the effectiveness and safety of probiotics in the prevention of infections in the elderly. Using systematized strategies, we searched for clinical trials available in the literature up to December 30, 2016, which had preferably included people over 65 years of age, comparing the use of probiotics with placebo. Two authors independently assessed the eligibility and quality of the studies, and extracted the data using the methodological procedures recommended by the Cochrane Collaboration. The main efficacy outcomes included infection prevention, quality of life, and mean duration per episode of infection, while safety outcomes included adverse events and mortality. The results were expressed as risk ratios, mean difference or standardized mean difference, as appropriate, with 95% confidence intervals using random effects metaanalysis, pooled where more than three estimates were available. When substantial heterogeneity was identified, potential causes were investigated, including subgroup analyzes. We used the GRADE tool to evaluate the quality of the evidence for each of the outcomes of interest. Main results: The search resulted in 5,036 citations. Excluding duplicates and applying the eligibility criteria, 15 studies were included. They evaluated 5,916 participants, with a mean age of 75.21 years, during a median follow-up of 319 days (204,75-631,50). The effect of probiotics on the occurrence of infections did not differ from that observed for placebo (13 studies, 5,820 participants: RR 0.90, 95% CI 0.76-1.08, I2 = 24%, moderate quality of evidence). No significant differences in effect estimates were observed when analyzing studies that included only elderly people, as well as in subgroup or sensitivity analyzes. The effects of probiotic consumption on the occurrence of adverse events and overall mortality were not statistically different from those observed for placebo (RR 1.01, 95% CI, 0.91-1.12, I2 = 0%, moderate quality of evidence, and RR 1.09, 95% CI 0.70-1.72, I2 = 5%, very low quality of evidence, respectively). Finally, the mean duration of infection episodes did not differ between the elderly who consumed probiotics compared to those who used placebo (seven studies, 1,406 participants, MD -0.35, 95% CI -1.57-0.87, I2 = 86%, poor quality of evidence). The subgroup analyzes were not able to reduce the heterogeneity of these outcomes; sensitivity analyzes did not modified the results. CONCLUSIONS: The use of probiotics did not appear to prevent infections or reduce the average duration of their episodes whean compared to placebo in older person.
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Palavras-chave
Idoso, Pessoa idosa, População idosa, Idoso de 80 anos ou mais, Probióticos, Infecções, Prevenção de infecções, Revisão sistemática, Metanálise