Can you write about Evidence Base Practice situation in nursing ?

Use of Probiotics in Infants with Diarrhea Associated with Antibiotics

Clinical Question

The problem this paper addresses is whether probiotics can be an effective preventative measure for diarrhea when a child is prescribed an antibiotic. The significance of this problem is that diarrhea can lead to serious complications in the very young and the elderly. Based on a six-month prospective cohort study by Vernacchio et al. (2006), diarrhea in infants and young children was reported to be 2.2 episodes per person-year with a median duration of 2 days. More of these were caused by viruses than bacteria. Although recent data are unavailable, a 1991 study by Glass, Lew, Gangarose, and LeBaron indicated that 325-425 children in the US die of diarrheal disease every year and 2.1 to 3.7 million children are seen by a physician for diarrheal diseases. C difficile infections are among the most serious causes of antibiotic-associated diarrhea and their incidence in hospitalized infants has been increasing (American Academy of Pediatrics Committee on Infectious Diseases, 2013). The major pathophysiology of the diarrhea associated with antibiotics is disturbance of the normal flora in the GI tract.

The specific clinical question guiding the search for a quantitative research article is: In hospitalized pediatric patients taking antibiotics, does taking probiotics decrease the risk of antibiotic associated diarrhea?

Population- hospitalized pediatric patients taking antibiotics Intervention- taking probiotics Comparison- not taking probiotics Outcome- reduction in diarrhea

Probiotics is the independent variable (IV) in this question and diarrhea is the dependent variable (DV). The population is hospitalized pediatric patients.

The specific clinical question guiding the search for a qualitative research article is:

What is the lived experience of parents with children who have acute diarrhea?

Population: parents

Outcome: lived experience of children having acute diarrhea

The variable of interest is: lived experience of having children with acute diarrhea. The population is parents.

Please note that a Time component is not relevant to these clinical questions because diarrhea is often self-limiting and short-term.

The purpose of this paper is to describe the systematic searches for the most-relevant evidence related to the topic of the use of probiotics in the care of children with acute diarrhea associated with antibiotics.

Levels of Evidence

Since the quantitative clinical question focuses on decreasing the risk of diarrhea associated with antibiotic use, it has a prevention focus. Like treatment questions, the levels of evidence and best evidence most relevant for this type of question are Levels I (multiple randomized control trials [RCT]) and Level II (single well-designed RCT). This is because the independent variable (probiotics) can be manipulated to determine their effectiveness in decreasing the risk of antibiotic associated diarrhea (the dependent variable). The level of evidence most relevant for the qualitative question is Level IV – one or more descriptive or qualitative studies.

CINAHL Search

The search was conducted through CINAHL using keywords, advanced search strategies, and CINAHL headings. For the search for quantitative evidence, the first keyword searched in CINAHL was the intervention “probiotics” which resulted in 3,982 results. Next, I searched the outcome “diarrhea” which resulted in 9,069 results. The keywords “probiotic” and “diarrhea” were combined and searched using AND which resulted in 507 results. For the advanced search, the limiters I chose were: English language, research, publication years 2009-2014, and the age groups from infant to 12 years (thinking those were the ages most affected by diarrhea). This produced 32 articles. In scanning them, I found that they included studies where the diarrhea was caused by many things, especially rotavirus. In order to remove these studies, I searched on the keyword “antibiotics” which produced 35,834 results. These results were added to the search on “probiotics AND diarrhea” which resulted in 219 results. A scan of these results showed that the majority was related to the clinical question but not limited to the pediatric population and when the previous limiters were applied, only 2 articles were produced. Then I used CINAHL Headings in order to conduct the most systematic search. The term “probiotics” produced 3753 results; “diarrhea” produced 6,297 results; and “antibiotics” produced 27,423 results. The combination of the three terms produced 178 results. This lower number reflected the greater precision in the results when CINAHL Headings are used. When the same limiters were applied, five articles were produced. Four of these were systematic reviews and were saved to use for the group project. The fifth article focused on the use of Kefir which is a cultured milk product. Since that is not frequently used in the US, I returned to the search that produced 178 results to find a quantitative article that fulfilled the requirements for this assignment and was relevant to my part of the group project. See search below:

Top of Form

Bottom of Form

To find a qualitative article that answers the second clinical question, The CINAHL Heading “parents” (which produced 26,899 results) was combined with the previous combination of “probiotics”, “diarrhea”, and “antibiotics”. This produced no results. I realized that this happened because “probiotics” and “antibiotics” limited the focus of the search too much so I combined “diarrhea” with “parents” and this combination produced 54 articles. A scan of these results showed that many were quantitative studies. I then limited this by the clinical query: qualitative – high specificity which produced two qualitative studies. Although not precisely focused on diarrhea, in consultation with the course instructor, a study of how parents decide to seek care for children with GI symptoms was chosen as appropriate for this assignment. See search below:

In the most relevant quantitative study, it was concluded that there are several strains of probiotics including, Lactobacillus GG and Saccharomyces boulardii, that are helpful in the prevention and treatment of antibiotic associated diarrhea (Jones, 2009). Administration of Lactobacillus GG has been shown to reduce antibiotic associated diarrhea by 75% in children in the United States.

In the most relevant qualitative study, it was found that making the decision to take a child to the emergency department is a complex process for parents. This decision involves expectations developed from community-level, family-level, and child factors. Issues of access to care affect parents' decision, including perceived level of urgency, travel time, and modes of transport available (Graham, Fitzpatrick, & Black, 2010).

References

American Academy of Pediatrics Committee on Infectious Diseases. (2013). Clostridium difficile infection in infants and children. Pediatrics, 131(1), 196-200. Doi:10.1542/peds.2012-2017.

Graham, J.M., Fitzpatrick, E.A., & Black, K.J. (2010). “My child can’t keep anything down!” Interviewing parents who bring their preschoolers to the emergency department for diarrhea, vomiting, and dehydration. Pediatric Emergency Care, 26(4), 251-256.

Jones, K. (2010). Probiotics: Preventing antibiotic-associated diarrhea. Journal for Specialists in

Pediatric Nursing, 15(2), 160-162.

Vernacchio, L., Vezina, R.M., Mitchell, A.A., Lesko, S.M., Plaut, A.G., & Acheson, D.W. (2006). Diarrhea in American infants and young children in the community setting: Incidence, clinical presentation and microbiology. The Pediatric Infectious Disease Journal, 25(1), 2-7. Doi: 10.1097/01.inf.0000195623.57945.87.