Evaluating Clostridioides difficile infection (CDI) treatment duration in hematology/oncology patients receiving concurrent non-CDI antibiotics

Abstract

Purpose To determine the impact of Clostridioides difficile infection (CDI) treatment duration on CDI recurrence in hematology/oncology patients receiving concurrent non-CDI antibiotics. Patients and methods This multi-site, retrospective study examined hematology/oncology patients age ≥18 years hospitalized with active CDI who received ≥1 dose of concurrent non-CDI antibiotics between September 2013 and June 2019. All patients were classified by two definitions for statistical analysis: standard (10-14 days) versus prolonged (>14 days) duration of CDI treatment and non-extended (≤24 hours after stopping non-CDI antibiotics) versus extended (>24 hours after stopping non-CDI antibiotics) CDI treatment. Primary outcome was CDI recurrence within 180 days of completing CDI treatment. Secondary outcomes included hospital length of stay (LOS) as well as mortality and incidence of vancomycin-resistant enterococcus (VRE) infections at 180 days. Results Of the 198 patients included, 112 were classified as prolonged versus 86 standard duration and 138 were classified as extended versus 60 non-extended duration. After accounting for demographic differences, no difference existed in the primary outcome of CDI recurrence in either prolonged versus standard or extended versus non-extended analysis (all p > 0.05). Patients who received prolonged versus standard CDI treatment had longer LOS (p < 0.0001) while no difference existed in extended versus non-extended (p > 0.05). No difference in mortality existed in prolonged versus standard (p > 0.05) while those who received extended versus non-extended CDI treatment had significantly lower mortality (p = 0.0008). Conclusions Neither prolonging CDI treatment beyond standard duration nor extending duration beyond end of non-CDI antibiotics was associated with decreased CDI recurrence rate.

Impact of oral vancomycin treatment duration on rate of Clostridioides difficile recurrence in patients requiring concurrent systemic antibiotics

“…[14][15][16] The median duration of vancomycin treatment in patients who had therapy prolonged was 20 days (IQR, [16][17][18][19][20][21][22][23][24][25][26], which is comparable to previously reported extended durations of 24-26 days. 14,15 Given the lack of available literature and treatment guidance from the IDSA for this population, we hypothesized reasons that clinicians may opt to prolong vancomycin treatment for CDI. We detected notable differences between patients who received vancomycin for a standard versus a prolonged duration that may have affected prescribing decisions.…”

“…Among the 218 patients included, 78 (36%) received a standard duration and 140 (64%) received a prolonged duration. Patients in the standard-duration and prolongedduration groups received vancomycin treatment for 13 (IQR, [11][12][13][14] days and 20 (IQR, 16-26) days, respectively (P < .001). Only 18 patients (8%) received vancomycin for 10 days.…”

“…Vancomycin was discontinued prior to antibiotics in 15 patients (7%), on the same day as antibiotics in 20 patients (9%), and after antibiotics in 183 patients (84%). Among patients who had vancomycin continued beyond antibiotic completion, most patients continued treatment dose (147 of 183, 80%) for a median of 6 days (IQR, 5-14) or prophylactic dose (30 of 183, 16%) for a median of 6 days (IQR, [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22].…”

“…Our recurrence rates were lower than published studies evaluating patients with CDI requiring concomitant antibiotics, with rates reported to be 21% within 8 weeks and 16%-29% within 6 months. [14][15][16] There may be several reasons for this difference. Oral metronidazole was used for CDI in 30%-70% of patients included in prior studies, which has been demonstrated to be inferior to vancomycin for CDI in terms of clinical cure and recurrence.…”

“…However, these studies were limited by prevalent use of oral metronidazole as primary treatment for CDI, lack of description of CDI disease severity, and short duration of follow-up or loss to follow-up. [14][15][16] Because CDI practice guidelines do not address duration of oral vancomycin treatment with concomitant systemic antibiotics that cannot be discontinued, vancomycin prescribing varies in this clinical scenario. It is unclear whether prolonging the duration of vancomycin in a high-risk cohort of hospitalized patients reduces the risk of disease recurrence.…”