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Prophylactic oral vancomycin does not consistently reduce risk for CDI relapse
Prophylactic oral vancomycin does not consistently reduce the risk for Clostridioides difficile infection, or CDI, relapse in patients receiving systemic antibiotics during hospitalization, researchers found.
Each year in the United States, there are more than 450,000 cases of CDI resulting in nearly 30,000 deaths. Moreover, the rate of CDI relapse is approximately 25%, underscoring a need to investigate “practical” ways to reduce recurrent infection, Daniel A. Caroff, MD, MPH, a postdoctoral fellow at Harvard Pilgrim Health Care and associate physician at Brigham and Women’s Hospital in Boston, and colleagues wrote.
“It has become common to see oral vancomycin used as prophylaxis, usually for patients with a history of C. difficile infection who require antibiotics for other reasons,” Caroff told Infectious Disease News. “We used a large population and robust statistical methods to account for many confounding factors but did not find a consistent benefit.”
Caroff and colleagues conducted a retrospective cohort study comparing CDI relapse rates in patients who started oral vancomycin at the same time as systemic antibiotics — the exposed group (n = 193) — with patients who did not (n = 567). They included adult patients with a history of CDI who received systemic antibiotics and were hospitalized at Brigham and Women’s Hospital or Massachusetts General Hospital between January 2009 and June 2015. Testing by toxin or nucleic acid at 90 days confirmed a CDI relapse.
Within 90 days, 9.8% of patients in the exposed group experienced a CDI relapse compared with 9.4% in the unexposed group (unadjusted OR = 1.06; 95% CI, 0.6-1.81; adjusted OR = 0.63; 95% CI, 0.35-1.14).
However, the findings did demonstrate a lower frequency of CDI relapse at 90 days among exposed patients with only one prior episode of CDI (OR = 0.42; 95% CI, 0.19-0.93) compared with exposed patients with more than one prior CDI episode (OR = 1.19; 95% CI, 0.42-3.33), showing the intervention may be beneficial for patients with only one prior CDI episode.
“The take-home message is that using oral vancomycin to prevent C. difficile relapse may not be as effective as previously thought,” Caroff said. “All available studies on this topic, including ours, have been retrospective. We need a prospective study to determine the true effect.” – by Marley Ghizzone
Disclosures: The authors report no relevant financial disclosures.
Perspective
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This paper provides important new information on the value of prophylactic vancomycin therapy to patients at increased risk for C. difficile colitis. Unfortunately, there is some disagreement between this and two other published studies on whether there is any value to simultaneous provision of vancomycin prophylaxis in this setting. Caroff and colleagues did not find statistically significant benefit in most situations for recommending this routinely, albeit there may be a subpopulation of patients with only a single episode who might benefit from such prophylaxis.
This paper reminds us of the need to identify better ways to prevent C. difficile colitis in high-risk patients. The most recent updated Infectious Diseases Society of America guidelines are a great place to start, yet more research needs to be done.
Numerous strategies have been examined, including using prophylactic probiotics; early empiric treatment upon initial onset of any loose stool; preferential use for treatment of certain newer (and much more expensive) agents instead of older agents; prophylactic treatment regimens using vancomycin or other less well-studied agents; changing and modifying the gastrointestinal microbiome using stool transplants; and the use of immunotherapies like bezlotoxumab. None of these modalities have demonstrated clear cut evidence of superiority vs. simply initiating treatment with effective therapy for proven recurrence as soon as it is diagnosed.
C. difficile remains one of the most important nosocomial infections. One essential all can agree upon is optimizing isolation of infected patients to reduce possible nosocomial transmission. However, even there, more needs to be understood regarding optimal duration of isolation, and how to address the increasing number of PCR-positive "carriers" of C. difficile that are identified.
It is a tribute to all physicians that today we have better recognition and awareness of C. difficile, leading to better control and prevention of this entity. However, we still remain far away from knowing the ideal, most cost-effective treatment and prophylactic regimens to use on our sickest of patients.
Reference:
McDonald LC, et al Clin Infect Dis. 2018;doi:10.1093/cid/cix1085.